Spinal Catheter for C-section in a Morbidly Obese Patient
Abstract Number: 27
Abstract Type: Case Report/Case Series
The patient is a 25 y/o G2P1 AAF at 38 weeks EGA who presented for a repeat c-section and BTL. PMH was significant for morbid obesity and HTN. Medications included Labetalol, Methyldopa, and PNV. Her weight was 510lb (230 kg). BMI of 73.18 kg/m2 which placed her in the hyperobese category. Airway exam was MP II, 3 FB thyromental distance, and decreased neck flexion due to chest diameter and excess soft tissue in the neck region. Physical exam was otherwise unremarkable. As her airway was a major concern, c-section with a spinal catheter was planned. The spinal catheter was placed in a sitting position using a Weiss needle. CSF was obtained at 10 cm. The catheter was threaded 5cm into the intrathecal space and was then bolused with 1.5 mls of 0.75% hyperbaric bupivicaine and 10mcg of fentanyl. She had a block to T4 bilaterally prior to incision. About 90 minutes into the case, the patient started to have minor return of sensation and motor function. The catheter was rebloused with a half ml of 0.75% bupivicaine in two incremental doses. She remained comfortable for the remainder of the procedure. She delivered a baby girl with APGARS of 9/9. Total surgical time was nearly 2 hours. EBL was 800ml. She was recovered for about 90 minutes and her block resolved uneventfully. The catheter was pulled in the PACU prior to transfer to the floor. She was discharged home on POD#2 after an uneventful recovery.
Obesity and pregnancy is becoming a more common problem encountered by anesthesiologists. Morbid obesity is associated with an increased anesthesia related maternal death during c-section. A recent review of maternal mortality in Michigan showed that 75% of the patients who died were obese [Mhyre]. Morbidity among parturients is most commonly due to airway management problems [Vallejo]. Obesity exaggerates the known airway challenges associated with pregnancy including increased chest diameter, airway edema, decreased FRC and difficulty positioning for intubation leading to problems with mask ventilation, laryngoscopy and intubation [Chestnut]. Additionally, general anesthesia may increase post-op pulmonary complications in obese patients. Given these factors, we felt that regional anesthesia was the best option for this obese patient. The failure rate for epidurals is significantly higher in obese patients [Mhyre] with up to 75% requiring multiple placement attempts. Additionally, c-section duration is often longer in obese patients, as was noted in our case. Thus, the option of a spinal catheter should be considered in this patient population to ensure a functioning block that can be augmented as needed throughout the case. This was an excellent option for this patient as a potentially difficult airway was averted and the patient remained comfortable throughout the entire duration of the case.