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

Spinal Failure in Marfan's: A Probable Cause

Abstract Number: 195
Abstract Type: Case Report/Case Series

Krupa P. Patel D.O.1 ; Mark Jackson MD2; Divina Santos MD3; Maria Messina MD4

In the following case report, we discuss a 34 year old G2P1 5'9" 72kg female who presented for a repeat cesarean section (C/S) in 2009. Two years prior, the patient had presented for a primary cesarean section and we had noticed an unusual response to local anesthetics. While most cases of failed or inadequate regional anesthetics are attributed to technical failure or failure of the medication, the clinical presentation and history of this patient suggests a possible genetic component to local anesthetic resistance.

Significant medical history in our patient includes a diagnosis of Marfan's Syndrome, ascending aortic aneurysm repair in 2005, mitral valve prolapse, mild scoliosis and possible emphysematous bullae. We had initially taken care of this patient for a primary C/S due to breech presentation. With the patients known cardiac history and the fetuss position, a regional anesthetic technique was implemented. Spinal anesthesia failed to develop after two full doses of spinal bupivacaine 0.75% with 10 mcg fentanyl and 0.2 mg morphine. A third spinal through a combined spinal epidural technique (CSE) was administered using 5% spinal lidocaine with 10 mcg fentanyl and 0.2 mg morphine which resulted in immediate spinal anesthesia adequate for surgery. The postoperative course was uncomplicated. It was concluded that she was insensitive to spinal bupivacaine but not lidocaine. In patients with Marfans syndrome, differential sensitivity to different local anesthetics and ductal ectasia have been previously reported.

In 2009, the patient returned for a repeat C/S. Having previously concluded that the patient had bupivacaine resistance, she received 100 mg of 5% spinal lidocaine with 10mcg fentanyl and 0.2mg morphine through a CSE. During insertion of the epidural catheter, spinal fluid was noted on aspiration. She failed to develop spinal anesthesia after 15 minutes and an additional dose of lidocaine (100mg) was administered through the intrathecal catheter. This dose also failed to develop adequate anesthesia. Spinal bupivacaine 15 mg was then administered with immediate development of an adequate spinal anesthesia. Postoperative recovery was unremarkable.

Further questioning revealed multiple prior episodes of delayed onset of sensory blockade with local anesthetics in this patient and her family. The perceived insensitivity to different local anesthetics does not appear to be the reason for our observed findings. Spinal anesthesia developed 45 minutes after the first spinal dose in each of these cases regardless of which local anesthetic was used. Could this apparent delayed response to spinal anesthesia be due to some genetic difference in patients with Marfan's? We await pharmacogenetic studies planned for this patient.

SOAP 2010