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

Anesthesiologist's nightmare: case report

Abstract Number: 186
Abstract Type: Case Report/Case Series

Gang Li MD, PhD1 ; Emily s Guimaraes MD2

We report on a patient in whom mental retardation, a trauma history, obesity, a recent fatty meal, fetal bradycardia, and refusal of IV access presented an anesthetic challenge.

A 25 year-old, 90 kg mentally retarded primigravida presented in labor. She was found to be pregnant at 32 weeks when she disclosed a rape. She was diagnosed with PTSD. Her pregnancy had been healthy, and she had a reassuring airway.

After arrival, she was noted to have 4 minutes of fetal deceleration to the 60s. Consent for emergent caesarean section was obtained from her mother, who was also her guardian. She had eaten a hamburger one hour earlier. She became combative upon mention of IV placement.

We hoped to avoid: an airway disaster; fetal compromise; and further psychological trauma. Our options included: forcible IV catheter placement; inhalation induction; oral sedation; IM ketamine; regional anesthesia was unlikely.

She was persuaded to enter the OR and then agreed to continuing fetal monitoring; this revealed reactive fetal heart rate in the 120s.

We planned parent-present induction, and began PO lorazepam; she remained uncooperative. 600 mg IM ketamine in divided doses was given, followed by supplementation with 50% nitrous oxide in oxygen, eventually resulting in a responsive patient in whom an IV could be placed. After preoxygenation, rapid sequence induction with propofol and succinylcholine was performed; intubation was easy. A boy with Apgars of 7 and 9 was promptly delivered. The parturient was extubated at the end of surgery, with no apparent complication. Both mother and grandmother were happy with her anesthetic.

Discussion: We hoped to achieve an induction that was both safe and humane in an uncooperative parturient without IV access and at high risk for aspiration. The anesthetic options for urgent Cesarean section in uncooperative parturients include oral or IM sedation, forceful IV placement, inhalation induction, or refusal of surgery; regional anesthesia may not be practical. Since the patients guardian had consented, refusal was not an option. Given the recent fatty meal and active labor, we felt that aspiration risk was high with inhalation induction. Our initial plan, in the setting of fetal bradycardia, was forcible IV placement. Once fetal monitoring became reassuring, in consultation with our OB team, we began with oral sedation. When this was inadequate, we moved to IM ketamine sedation with supplemental nitrous oxide, which resulted in successful IV placement followed by rapid sequence induction and intubation.

This case illustrates the need for dynamic modification of anesthesia plans, the importance of communication in OB crises, an intersection between obstetric and pediatric anesthesia, and a safe use of ketamine and nitrous oxide in an uncooperative parturient with a full stomach.


1. Br J Anaesth. 2001 Jun;86(6):891-3. 

2. Masui. 2006 Oct;55(10):1225-7.

3. Anesthesiology. 1997 Jun; 86(6): 1392-1394

SOAP 2010