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A parturient with multinodular goiter (retrosternal extension with significant tracheal compression) and active upper respiratory tract infection for elective cesarean section
Abstract Number: 184
Abstract Type: Case Report/Case Series
CP, at 39 week gestational age was scheduled for an elective repeat cesarean section. Her medical history was significant for hypertension, morbid obesity (BMI 46), obstructive sleep apnea (by history with a STOP-BANG score of 12), and a goiter with retrosternal extension, causing narrowing of the trachea to 1.5x0.6cm. She was unable to lie supine and had to use two pillows. She had a Malampatti 3 airway and a short neck. She developed an upper respiratory infection two days before the scheduled surgery with nasal congestion and dry cough.
On the day of surgery, she continued to have these symptoms, was unable to lie supine, and was sitting up breathing orally. She was afebrile and her lungs sounded clear to auscultation. Though she was scheduled for an elective surgery, the team decided that it is imprudent to postpone surgery as we did not wish to risk her coming back during the following holiday weekend requiring to be operated on an emergent basis. So we treated her symptomatically in the holding area, with phenylephrine nasal drops and cough syrup. Her symptoms improved in a couple of hours to the extent of enabling her to lie supine with two pillows.
Regional anesthesia was planned, and seemed safer in her than general anesthesia in view of the goiter with tracheal compression, reactive airway, morbid obesity, Malampatti 3 airway. But on the other hand we were cognizant of the risks of neuraxial anesthesia in her, i.e., the risk of high spinal and need to procure airway in a crisis situation. Hence we opted on a modified combined spinal anesthesia (CSE). We had the difficult airway cart including a fibreoptic bronchoscope ready in the OR.
In the OR, we prepared her to be positioned with the shoulder elevated, so that the head assumes the "sniffing position" in case a need to intubate arose. We performed CSE at L3-4 level in the sitting position with a small dose of 0.75% spinal bupivacaine (0.5ml) with fentanyl 15mcg and morphine 250mcg to get a low thoracic block. After placing her supine with left uterine displacement, we built up sensory level to T4 with epidural lidocaine 2% with epinephrine in small incremental doses, over 20 minutes, assessing her sensory level and ability to breathe comfortably after each dose. She was able to lie supine and even have her pannus pulled over her chest and taped. The cesarean section was performed uneventfully and she was transferred to the PACU.