LETTERS TO EDITOR

MANAGEMENT OF HELLP SYNDROME

Dear editor;

I read the article by M Zameer Rajput et.al (1) concerning management of HELLP syndrome with interest. This article provides useful information about HELLP syndrome, but I want to add two things.

First, at present, there are two major definitions for diagnosing the HELLP syndrome. These are Tennessee Classification System and Mississippi-Triple Class System. In the Tennessee Classification System diagnostic criteria for HELLP are haemolysis with increased LDH (> 600 U/L), AST (≥ 70 U/L), and platelets < 100·10⁹/L. The Mississippi Triple-class HELLP System further classifies the disorder by the nadir platelet counts (2).

Secondly, the most dramatic sequelae of hepatic involvement by preeclampsia is subcapsular hematoma. Spontaneous rupture of a subcapsular liver haematoma in pregnancy is a rare, but life threatening complication. The symptoms are sudden-onset severe pain in the epigastric and right upper abdominal quadrant radiating to the back, right shoulder pain, anaemia and hypotension. The condition may be diagnosed by ultrasound, CT or magnetic resonance imaging (MRI) examination (2).

Finally, the use of classification systems is very important in management of diagnosed patients and to determine the severity of the disease. Also, radiological imaging of right upper abdomen is important to rule out the diagnosis of subcapsular hepatic hematoma in HELLP syndrome.

REFERENCES

Rajput MZ, Rehman A, Baig H. Management of HELLP syndrome. Anaesth Pain & Intensive Care 2010;14(1):46-48.

Kjell Haram et al. The HELLP syndrome: Clinical issues and management. A Review BMC Pregnancy and Childbirth 2009, 9:8

Mehmet Kizilkaya, MD

Associate Professor

Department of Anesthesiology and Reanimation

Ataturk University Loj. No: 60/20 25240, Erzurum (Turkey)

E-mail: mkizilkaya65@hotmail.com

Phone Number: +90 5422323669

Authors’ Reply;

Dear Sir, thank you very much for your interest in our article. We fully agree to your comments regarding new classifications of the syndrome. Life sciences are changing at a fast pace and new inroads are being made in evidence based medical practice. In our patient, LDH and AST levels were well beyond those mentioned as lower limit in Tennessee Classification System. Ultrasound examination was done, however, it revealed no subcapsular hematoma. We emphasise that this possibility should be kept in mind in all HELLP syndrome patients.

Dr. M. Zameer Rajput, MCPS, FCPS.

Professor of Anaesthesiology

Director Intensive care unit

Shifa International Hospital

Islamabad (Pakistan).

SAFETY OF LMA AND I-GEL

Dear editor;

I read with interest the article by Siddiqui AS et.al (1) concerning LMA and i-gel. This article gives good information about supraglottic airway devices, but it needs some additions.

First, the patients, the usage of supraglottic airway devices has increased, but it is not recommended for routine use in all cases of elective general anaesthesia because of some worries about airway security.

In the article, it has been stated that bloodstaining on LMA after removal was because of pharyngolaryngeal trauma, but, in this study the cuff pressure of the LMA wasn’t measured. It could vary in different patients and tremendous pressures can be applied in some of them causing pharyngolaryngeal trauma. Due to this shortcoming in the study, it is hard to conclude that i-gel has lower morbidity rate.

While supraglottic airway devices are being used, the level of the EtCO2 can give useful information about correct placement of the LMA and i-gel. Moreover, the capnograph is required to establish effective ventilation. In this experiment, we can’t find information about the measurement of end-tidal CO2.

Comparison of performance and safety of i-gel with laryngeal mask airway (classic) for general anaesthesia with controlled ventilation” (Anesth, Pain & İntensive Care. Vol.14(1), pp 17-20)