///2010 Abstract Details
2010 Abstract Details2019-08-03T15:49:10-05:00

Anesthetic Management of a Supermobidly Obese Patient with Subaortic Stenosis and a Family History of Malignant Hyperthermia

Abstract Number: 143
Abstract Type: Case Report/Case Series

Robert N Fish M.D.1 ; Amy E Young M.D.2; Karen K Wilkins M.D.3

Introduction: Subaortic stenosis, supermorbid obesity, and malignant hyperthermia are conditions known to add complexity to anesthetic management. When these conditions are present in a parturient with chronic hypertension, obstructive sleep apnea, and gestational diabetes, the anesthetic care provided is vital for a positive outcome. We describe the anesthetic management of this patient.

Case Presentation: A gravida 5, parida 2, 38-year-old female presented at 36 weeks gestation with dyspnea on exertion. She underwent echocardiographic evaluation which revealed subvalvular left ventricular outflow tract obstruction with a 77 mm Hg peak gradient and moderate left ventricular hypertrophy. She was admitted to the intensive care unit where delivery was to take place with continuous patient and fetal monitoring. At 37 weeks gestation, induction of labor was initiated. An arterial line and large bore central venous line were in place. A lumbar epidural was placed and slowly dosed for a planned assisted second stage delivery without the patient pushing.

Induction of labor was stopped early when the patient developed chest pain. Ultrasound examination showed the fetus was in a breech position, and the patient was scheduled for an elective Cesarean section the following day. Both cardiac and obstetric anesthesiologists were present for the case. Preparation for awake fiberoptic intubation was undertaken with administration of incremental doses of intravenous glycopyrolate. The patients heart rate was controlled with an esmolol infusion. Her airway was topicalized with lidocaine and awake fiberoptic intubation was performed under light sedation using midazolam and remifentanil. When the endotracheal tube position was confirmed, general anesthesia was induced with slow administration of propofol. Vecuronium was subsequently given. The patient was maintained on a total intravenous anesthetic with remifentanil and propofol infusions. Intraoperative transesophageal echocardiography was performed to monitor cardiac status. The baby was successfully delivered with Apgars of 2 and 9 at 1 minute and 5 minutes, respectively. The patient tolerated the procedure well and was extubated in the operating room without incident.

Discussion: Anesthetic management for each of this patients conditions is well described in anesthesia literature. This case is unique in the number of life threatening comorbidities it combines. In difficult obstetric patients such as this, an anesthetic plan should be established as early as possible because urgent and emergent surgeries are frequently encountered in these patients. A multidisciplinary approach with input from other medical specialties can help optimize care. Communication with the surgeons and other team members is essential in this setting. With careful thought, planning, and preparation, a safe anesthetic can be administered in very complex patients.

SOAP 2010