///2009 Abstract Details
2009 Abstract Details2019-08-03T15:55:31-06:00

Anesthetic management of a parturient with Arnold-Chiari type I malformation and Blue Rubber Bleb Nevus Syndrome for primary C-Section.

Abstract Number: 108
Abstract Type: Case Report/Case Series

Eduard Logvinskiy D.O.1 ; kalpana tyagarag MD2; ranya mohammed MD3

INTRODUCTION: Patient with Arnold Chiari malformation-I and Blue Rubber Bleb Nevus Syndrome BRBNS presents a distinctive challenge in anesthetic management. In the presence of this malformation, neuraxial blocks are questionable regarding their safety.

CASE REPORT: 22 years female G1P0 at 42 wks gestational age, with history of ACM-I and cutaneous form of BRBNS presents for labor induction. Her history was significant for ACM-I, an incidental diagnosis and patient was symptomatic. On examination, she had good mouth opening, TM distance 5cm, grade 3 Mallampati scale and good range of cervical spine mobility. Neurological examination was unremarkable and no symptoms of raised intracranial pressure (ICP). Skin examination revealed multiple dark blue, compressible blebs on back and trunk. Patients hematocrit was 32.6 and platelet count 225 K/uL. Patient understood the risks of epidural placement and informed consent was obtained. Epidural catheter was placed at the L3-4 interspace, with loss of resistance to saline. A test dose of 5 ml of 1.5% lidocaine with 5 mcg/ml epinephrine was given and an epidural block was established incrementally over 20 mins with 10 ml of 0.25% bupivicaine. Infusion with 0.1% bupivicaine with fentanyl 2mcgs/ml, at rate of 10 ml/hr started. Patient had good pain relief. After 6 hrs, patient was taken for emergent C-section for non-reassuring fetal heart rate. Large bore intravenous lines were inserted. Incremental doses of 2% lidocaine and 5mcg/ml epinephrine was given through the epidural catheter. Epidural blockade extended from sacral dermatomes to the 4th thoracic dermatomes bilaterally. After the delivery of the baby, excessive bleeding was noted. In addition to Oxytocin, 0.2 mg Carboprost Tromethamine intrauterine and IM was administered with subsequent control of bleeding. 2.5 mg of preservative free morphine was administered for post-op pain management and catheter removed. Estimated intra-op blood loss was 1500ml. Postoperative hematocrit was 21 and patient was transfused with 2 units of PRBC, with subsequent rise of hct to 27. Throughout, she remained hemodynamically stable. She was discharged a few days later.

DISCUSSION: BRBNS is a rare condition that is characterized by cutaneous and visceral venous malformations with a potential for life-threatening hemorrhage. Despite limited experience of central neuraxial blocks in patients with ACM-I and BRBNS, they appear to be safe and effective in select patients. Patients should be thoroughly evaluated, especially for signs of increased ICP and existing neurological deficits. MRI imaging to rule out spinal and uterine venous malformations may allow for safe use of neuroaxial anesthetic techniques and prepare for potential massive hemorrhage. Availability of alternative options for anesthetic management and weighing the risks versus benefits is critical for the optimum management and to reduce the potential risk maternal of morbidity and mortality.

SOAP 2009