Patients with Turner syndrome with multiple co-morbidities and associated anti-NMDA limbic encephalitis are a challenge for attending anesthesiologists. They are at risk of perioperative complications. Combined Spinal anesthesia is a safe alternative in these patients, but one must be cautious to maintain level of blockade and hemodynamics.

1. ANESTHETIC MANAGEMENT OF A GERIATRIC FEMALE, A CASE OF TURNER
SYNDROME WITH ANTI-NMDA LIMBIC ENCEPHALITIS AND MULTIPLE CO-
MORBIDITIES FOR REPAIR OF FRACTURE FEMUR
Dr. BHAVNA GUPTA*, Dr. Munisha Agarwal , Dr.Vandana Saith
Department of Anaesthesia at Maulana Azad Medical College and LNH
INTRODUCTION
PREOP INVESTIGATIONS
CASE REPORT DISCUSSION
•Hb-12.0 g/dl
•TLC- 6500 cells/mm3
•Platelet count- 2.2/l
•Blood urea 19 mg%
•S.E and LFT’s-WNL
•PT INR- 1.1
•high titers of anti-thyroid peroxidase, anti-
thyroglobulin
Her HRCT thorax B/L PE, sub segmental lung
collapse and moderate Pericardial effusion
CSF
MRI
ANTI NMDA
NMDA antagonists like ketamine, nitrous oxide, xenon, tramadol, methadone, and
phencyclidine are avoided in this condition because their effects are unpredictable and
may worsen the course of the disease. Pascual-Ramírez et al. have used a combination
of propofol, sevoflurane, and fentanyl in a case with no complications. Although
propofol is considered a safe drug as it does not act via NMDA receptors, and a few
authors have used it with no complications, some case reports document severe
unexpected hypotension in the patient on using propofol induction. Therefore, a single
drug cannot be labeled as safe for use in limbic encephalitis. Hemodynamic instability
was expected owing to autonomic instability and associated anti-limbic NMDA
encephalitis.
Patients with Turner syndrome with multiple co-morbidities
and associated anti-NMDA limbic encephalitis are a challenge
for attending anesthesiologists. They are at risk of
perioperative complications. Combined Spinal anesthesia is a
safe alternative in these patients, but one must be cautious to
maintain level of blockade and hemodynamics.
A 68 year old female
short statured (140cm),
Weighing 48kg,
webbed neck, webbed
toes, Sensory neural
hearing loss,
Hearing aids in ear,
Disturbed mentation
Vitals:
PR= 80/min,
BP= 150/80 mmHg
RR= 12/min,
Chest- clear
CVS: S1 S2 normal
Coronary triple vessel disease, diabetes, hypertension,
hypothyroidism, gastro-esophageal reflux disease,
psychiatric illness, severe osteoporosis and severe
SNHL.
Clopidegrel,
Ecospirin,
Atorvastatin
Ramipril,
Metoprolol
Metformin,
glimepiride
Levothyroxi
ne, Steroids
Quetiapin
e
Zoledronic
acid,
Vitamin
D3,
calcium
A 65 year old female, case of Turner syndrome, multiple
co-morbidities and anti NMDA limbic encephalitis
Planned for Repair of IT femur
Anti-N-methyl D-aspartate receptor (NMDA) receptor limbic encephalitis
CSF-normal; MRI brain-limbic encephalitis
Evaluation of her symptoms revealed autonomic dysfunction
An episode of hypotension
SAB- L2-3, 4 mg heavy bupivacaine and 15µg fentanyl
EPIDURAL L1-2 OMISSION OFTEST DOSE INITIALLY.
Preloading
Routine standard monitors, Invasive BP monitoring
Clopidogrel was stopped seven days prior to surgery, and Ramipril
and metformin were stopped on the day of surgery.
Patient shifted to HDU and monitored for 24 hours
Blood loss 300 ml, fluid blouses dobutamine
SensoryT 6 motorT 8 Duration lasted for 2 hours
CONCLUSION
Limbic encephalitis is characterized by subacute
impairment of memory, psychotic behavior, and
seizure disorder; autoimmune anti-NMDA
encephalitis is a rare entity that has been described
since 2007 . Anti-NMDA encephalitis exclusively
involves limbic regions and is characterized by
psychotic behavioral changes, autonomic
dysfunction, and movement disorders . There is a
paucity of literature on the anesthetic concerns in a
case of autoimmune limbic encephalitis; many
authors have recommended general anesthesia
FACTORS AGAINST GENERAL ANAESTHESIA
AVOID NMDA antagonists
(ketamine, nitrous oxide, xenon,
tramadol, methadone and
phencyclidine)- Abnormal
Responses
Delay in reversal of
airway reflexes
Post-
operative
delirium
Post op
pulmonary
complications
Possible need of
ventilation in post-
operative period.
Risk of
aspiration
Risk of high level of
blockade
Autonomic
instability
Therefore we preferred, CSE: to titrate the level of
blockade, prevent chances of profound hypotension.
FACTORS AGAINST SPINAL ANAESTHESIA
 J. Dalmau,A.J. Gleichman, E.G. Hughes, et al.Anti-NMDA-receptor encephalitis: case series and analysis of the
effects of antibodies. Lancet Neurol 2008;1091-8.
 Pascual-Ramírez J, Muñoz-Torrero JJ, Bacci L,Trujillo SG, García-Serrano N. Anesthetic management of ovarian
teratoma excision associated with anti-N-methyl-D-aspartate receptor encephalitis. Int J Gynaecol
Obstet 2011;115:291–2.
 Liao Z, Jiang X, Ni J. Anesthesia management of cesarean section in parturient with anti-N-methyl-D-aspartate
receptor encephalitis: a case report. J Anesth 2017;32:282-5.
 Chaw SH, et al.Anesthesia in anti-N-methyl-d-aspartate receptor encephalitis - is general anesthesia a requisite? A
case report. Rev Bras Anestesiol 2015;26.
 SplinterWM, Eipe N.Anti-NMDA receptor antibodies encephali-tis. PaediatrAnaesth 2009;19:911.
REFERENCES
Profound
hypotension