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Year : 2009  |  Volume : 53  |  Issue : 1  |  Page : 68-70 Table of Contents     

Anaesthetic Management of A Case of Osteogenesis Imperfecta with Urinary Bladder Stone-A Case Report

1 Assistant Prof, Department of Anesthesiology & Critical Care, Subharti Medical College, Meerut, U.P., India
2 Associate Prof, Department of Anesthesiology & Critical Care, Subharti Medical College, Meerut, U.P., India

Date of Web Publication3-Mar-2010

Correspondence Address:
Munish Garg
Flat No.11, XBlock,Subharti Medical College, Delhi Haridwar Byepass Road Meerut (U.P.)
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Source of Support: None, Conflict of Interest: None

PMID: 20640081

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Sometimes in practice of anaesthesia, anaesthesiologist encounters patients with rare congenital diseases. To anaesthesiologist, these patients are a challenge due to inherent complications associated with the disease. Here, we are reporting a case of osteogenesis imperfecta who was posted for the surgery for vesical calculus. All investiga­tions were done to rule out any cardio-respiratory abnormalities, bleeding disorders, which are commonly associated with these patients. Caudal epidural was chosen as anaesthesia technique of choice as spinal anaesthesia was anticipated to be difficult due to associated kyphoscoliosis. GA was avoided due to anticipated difficult airway, restrictive lung disease and susceptibility to malignant hyperthermia. We emphasize the importance of proper preanaesthetic evaluation, intellectual, mental and logistical preparation which should be done before anaesthetising these types of patients.

Keywords: Osteogenesis Imperfecta, Bladder stone, Anaesthesia

How to cite this article:
Garg M, Jain M, Gupta A. Anaesthetic Management of A Case of Osteogenesis Imperfecta with Urinary Bladder Stone-A Case Report. Indian J Anaesth 2009;53:68-70

How to cite this URL:
Garg M, Jain M, Gupta A. Anaesthetic Management of A Case of Osteogenesis Imperfecta with Urinary Bladder Stone-A Case Report. Indian J Anaesth [serial online] 2009 [cited 2020 Oct 26];53:68-70. Available from: https://www.ijaweb.org/text.asp?2009/53/1/68/60260

   Introduction Top

Osteogenesis imperfect (OI), also known as brittle bone disease, is agenetic disorder of connective tissue characterized by bones that fracture easily, often with little or no trauma. Osteogenesis imperfecta is caused by a faulty genethat instruct to make too little or poor quality of type 1 collagen [1] . The prevalence of osteogenesis imperfecta ranges from 1:60000 to 1:20000 [2] depending upon type of OI. Inheritance in nearly all cases follows an autosomal dominance pat­tern, although sporadic casesare common. The disor­der is frequently associated with blue sclera, dental abnormalities [3] (dentinogenesis imperfecta), progressive hearing loss, and a positive family history. The most common classification for OI was developed by Sillence [4] .

Anaesthetic implication of OI includes diffi­cult intubation [5] , platelet dysfunction, cardiovascular ab­normalities like mitral valve prolapse [6],[7] , tendency to develop malignant hyperthermia [8],[9] and problems with positioning of patient due to brittle bones.

   Case Report Top

A 54-year-old male patient presented in emer­gency room with acute retention of urine. He was a known case of OI tarda [Figure 1]. Immediately foley's catheterization (no.-16fr.) was done to relieve reten­tion. X-Ray KUB of the patient revealed a right side renal calculus and a vesicle calculus and was planned for cystolithotomy [Figure 2].

On preanaesthetic evaluation,the patient weighed 22kg, length 94cm, head circumference 50cm, chest circumference 65 cm, and was bedridden. He had un­dergone previously cystolithotomy at 6 months of age (details ofthat operation were not available). History revealed uneventful antenatal period and no delay in milestones. Patient developed normally upto 10yr of age and after that he started having skeletal fractures. There was no positive family history.

Investigation revealed Hb 12.6g%, TLC 9300, platelet count 2.3 lacs, blood sugar 86 mg/dl, blood urea 40.4 mg/dl, serum creatinine 0.6 mg/dl, serum potassium 4.5meq/l,serum sodium 143meq/l, serum calcium 8.7meq/l.

Preoperative coagulation profile was normal. 2D echo revealed no valvular abnormalities and normal ejection fraction (64%). Pulmonary function tests re­vealed a moderate degree of restrictive lung disease.

The patient was accepted for surgery as ASA grade II. In view of anticipated difficult airway, it was planned to conduct the case under regional anaesthe­sia. In the operation theatre, i.v. line was secured using 18Gcannula. Monitoring included 5 lead ECG, manual blood pressure monitoring, SpO2, EtCO2, and tem­perature. Difficult airway cart was also kept standby. After preloading with 500ml of Ringer lactate i.v., caudal epidural anaesthesia was given in lateral position with 14ml of 0.25% of bupivacaine. Midazolam 1.0mg and butorphanol 1.0mg i.v. was given for sedation. During surgery, his vitals remained stable and no rescue medi­cation was required. Operation lasted for about 40min and patient had an uneventful recovery. He was dis­charged on 5 th postoperative day.

   Discussion Top

Osteogenesis imperfecta is a rare autosomal dominant inherited disease of connective tissues that affects bones, sclera and inner ear [10] . The incidence is higher in females. Clinically, it occurs in two forms: os­teogenesis imperfecta congenita and osteogenic imperfecta tarda. With congenital forms fractures oc­cur in utero and death is usually in perinatal period.The tarda form typically manifests during childhood or early adolescence, but the patients have a normal life span.

Management of anaesthesia is influenced by co­existing orthopaedicde formities [11] , vulnerabilitiest of rac­ture during perioperative period, associated cardiac abnormities, impaired platelet function, tendency to develop hyperthermia and rarely extra skeletal mani­festations [12] . Due to abnormal skeletal growth difficult airway must always be anticipated in such patients. Associated kyphoscoliosis along with pectus carinatum may decrease vital capacity, chest wall compliance with resulting arterial hypoxemia due to ventilation perfu­sion mismatch and this can lead to increased risk under GA. Succinylcholine should be avoided as fascicula­tion can lead to fractures. Regional anaesthesia is ac­ceptable in selected patients as it avoids need for tra­cheal intubation but may be difficult because of ky­phoscoliosis. Before giving regional anaesthesia, co­agulation profile must be screened due to associated increase in bleeding time despite normal platelet count [13] .

For monitoring of blood pressure, automated blood pressure cuffs may be hazardous as over infla­tion may result in fracture. During prolonged surgery, all pressure points should be well padded and posi­tioning of patient along with transportation [14] should be very gentle to prevent occurrence of fracture.

There have been several successful case reports of conductance of surgery under general anaesthesia in patients with osteogenesis imperfecta. Karabiyik et al [1] have recommended TIVA along with ILMA to manage elective case, while Malde et al [14] have successfully used balanced general anaesthesia in a case of osteogenesis imperfecta with gross deformity of pelvis for abdomi­nal hysterectomy.

In our patient, we avoided general anaesthesia due to anticipated difficult airway (attributed to limited mo­bility of cervical spine, short neck and absent denti­tion), restrictive lung disease (due to associated kyphoscliosis, pectuscarinatum) and susceptibility to malignant hyperthermia. However, preparation was kept ready in operation theatre for managing difficult airway in case of emergency.

We preferred regional anaesthesia since the pa­tient had to undergo a lower abdominal surgery and to avoid risk related to general anaesthesia. Before giving regional anaesthesiaa thorough preoperative workup of patient was done with special attention to coagula­tion profile as these patients are prone to have abnor­mal bleeding tendencies. Patient's BT, CT and PT were within normallimits. Caudal epidural was chosen as preferred anaesthesia technique over spinal anaesthesia as it was difficult to perform lumbar puncture due to associated kyphoscoliosis and unpredictability of the level of block. The effect of caudal block was till T10 level and course of surgery was uneventful.

To summarise, patients with OI pose a significant challenge to anaesthesiologist owing to difficult airway, problems with positioning, fractures, tendency for hy­perthermia and platelet functional abnormalities. Only thorough preoperative workup and prompt manage­ment can improve the outcome in these patients.

   References Top

1.Karabiyik L, Parpucu M,Kurtipek O. Total intravenous anaesthesia and the use of an intubating laryngeal mask in a patient with Osteogenesis Imperfecta. Acta AnaesthesiologyScand2002;46:618-19.  Back to cited text no. 1      
2.Darwin J Prockop, Leena Ala-Kokko. Inherited disor­ders of connective tissue. Harrisons Principles of Inter­nal Medicine 16 th Ed.  Back to cited text no. 2      
3.Malmgren B, Norgren S. Dental aberrations in children and adolescents with osteogenesis imperfecta. Acta Odontol Scand2002;60:65-71.  Back to cited text no. 3      
4.Sillence DO, SennA, Danks DM. Genetic heterogeneity in osteogenesis imperfecta. Journal of Medical Genet­ics1979;16: 101-116.  Back to cited text no. 4      
5.Colvin MP, Wilkinson K. Patient position. In: Taylor TH, Major E, eds. Hazards and complications of anaes­thesia. Edinburgh: Churchill Livingstone, Inc1993: 535-­60.  Back to cited text no. 5      
6.Wood SJ, Thomas J, Brainbridge MV, et al . Mitral valve disease and open heart surgery in osteogenesis Imperfecta tarda: report of a case. Br heart J 1973;35:103-6.  Back to cited text no. 6      
7.Byers PH. Osteogenesis Imperfecta. In: Royce PM. Steinmann B. eds. Connective tissue and its heritable disorders. Molecular, genetic and medical aspects. New York: Wiley-Liss1993: 317- 50.  Back to cited text no. 7      
8.Porsberg P, Astrup G, BendixenD, LundAM, Ording H. Osteogenesis imperfecta and malignant hyperthermia. Is therea relationship? Anaesthesia 1996;51: 863-65.  Back to cited text no. 8      
9.Rampton AJ , KellyDA, Shanahan EC, Ingram GS. Oc­currence of malignanant hyperpyrexia in a patient with osteogenesis imperfecta. Br J Anaesth1984;56:1443-46.  Back to cited text no. 9      
10.Kuurila K, Grenman R, Johansson R, Kaitila I. Hearing loss in children with osteogenesis imperfecta. European Journal of Pediatrics 2000;159: 515-519.  Back to cited text no. 10      
11.Glorieux FH, Ward,LM, Rauch F, LalicL, RoughleyPJ, Travers R. Osteogenesis imperfecta type VI: a form of brittle bone disease with a mineralization defect. Jour­nal of Bone and Mineral Research2002;17: 30-38.  Back to cited text no. 11      
12.Venugopala d, Babu S, Korath MP, Jagadeesan K. Renal stone disease as extra skeletal manifestation of osteo­genesis imperfecta. J Assoc Physicians India 2000; 48: 1027-28.  Back to cited text no. 12      
13.Edge G, Okafor B, Fennelly ME, Ransford AO. An un­usual manifestation of bleeding diathesis in a patient with osteogenesis imperfecta. Eur J Anaesthesiol 1997; 14:215-9.  Back to cited text no. 13      
14.Malde AD, JagtapSR, Pantvaidya SH,Kenkare JS. Os­teogenesis Imperfecta: Anaesthetic management of a patient for abdominal hysterectomy (a case report). In­dian J Anaesthesia1993;41: 203-06.  Back to cited text no. 14      


  [Figure 1], [Figure 2]


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