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

The Use Of Remifentanil In The Management Two Parturients Undergoing Elective Cesarean Section Then Craniotomy

Abstract Number: 234
Abstract Type: Case Report/Case Series

Erin S Williams MD1 ; George W Williams, II MD2; Susan D Dumas MD3; Barbara F Dabb MD4

Intracranial neoplasm during pregnancy is an uncommon clinical scenario. The incidence of brain tumors in women is approximately 6 in 100,000 patients and neurologic masses are not more common during pregnancy. When faced with neurosurgery for the parturient, the goals of anesthetic management are multifaceted and the use of remifentanil can be advantageous. We present two cases in which remifenantil was used for parturients with brain tumors.

Case # 1: A 32-year-old female at 32 weeks gestation presented with a 10 day history of headache, nausea, vomiting, and generalized weakness. A left cerebellar mass was found on MRA. After discussions with the neurosurgeon, obstetrician and anesthesiologist, she was scheduled for sequential surgeries including ventriculostomy, cesarean section, and craniotomy. Anesthetic management included a rapid sequence induction with thiopental, propofol, and rocuronium. The patient was maintained on sevoflurane, oxygen, air and a remifentanil infusion. Ventriculostomy was performed first. The baby was then delivered via cesaerean section. The patient was subsequently turned prone for removal of the tumor. The tumor diagnosis was cellular schwannoma. The patient remained stable in the Neurosurgical Intensive Care Unit and was ultimately discharged in stable condition on POD# 6. The infant remained in the Neonatal Intensive Care Unit and was discharged to home 4 weeks later with no chronic medical illness.

Case # 2: A 20-year-old Jehovahs Witness female at 29 3/7 weeks gestational age who weighed 94kg and presented with a 3 week history of nausea, weakness, dizziness and double vision. Preoperative MRI of the head demonstrated a suprasellar mass measuring 4.6 X 2.6 x 2.6 cm. Following consultation between the neurosurgeon, obstetrician, and anesthesiologist, the surgical plan called for a ventriculostomy drain placement followed by an immediate cesarean section with preoperative steroid administration. The patient underwent a modified rapid sequence induction with lidocaine, thiopental and rocuronium. General anesthesia was maintained with sevoflurane, oxygen, air, propofol and a remifentanil infusion. Following placement of the ventriculostomy drain, the baby was delivered via cesarean section and transferred to the NICU. The patient returned to the OR on POD #14 as planned for craniotomy; the tumor was determined to be a pilocystic astrocytoma. One month following the initial surgery, the patient was discharged for rehabilitation.

Discussion: Kan et al demonstrated that remifentanil crosses the placenta however, in the fetus it appears to be rapidly distributed, metabolized, or both. Given this beneficial profile of remifentanil, anesthesiologists can possibly add this drug to their armamentarium when treating the pregnant patient with conditions that warrant urgent/emergent surgical intervention.

SOAP 2009