///2010 Abstract Details
2010 Abstract Details2018-05-01T17:52:49+00:00

Neuraxial Anesthesia in a Super Obese Patient for Cesarean Delivery

Abstract Number: 242
Abstract Type: Case Report/Case Series

Neil M DiGiovanni MD1 ; Elizabeth I Krenz MD2; Russo B Melissa MD3; Stuart R Hart MD4

Introduction: The prevalence of morbid obesity is increasing rapidly in the United States. Obese parturients have more anesthetic complications and increased maternal mortality and morbidity following cesarean delivery. We describe a super obese (SO) patient successfully undergoing cesarean delivery, via a supraumbilical vertical incision, under spinal anesthesia.

Case report: A 32 year old female at 38 weeks gestational age presented for repeat cesarean delivery. An epidural had been placed two days earlier at an outside institution for planned cesarean delivery. When the epidural was dosed, incomplete anesthesia was noted and the decision was made to remove the epidural catheter, postpone delivery and transfer her to our tertiary care center. The patient was 61 inches tall and weighed 180 kg (BMI 74.8). She had severe uncontrolled asthma, obstructive sleep apnea, and lower abdominal cellulitis. She had bilateral expiratory wheezing and a Mallampati class 3 airway. Combined spinal epidural (CSE) anesthesia was planned due to her history of inadequate sensory block with epidural anesthesia and to avoid a general anesthetic in the event of a prolonged operation. Attempts to visualize the epidural space using ultrasound were unsuccessful. A 17 gauge 13 cm epidural needle was placed at the L 3-4 intervertebral space using a loss of resistance technique, and a 16 cm 25 gauge spinal needle was advanced through the epidural needle. 1.8 ml (13.5 mg) of 0.75% isobaric bupivicaine with 10 mcg of fentanyl and 150 mcg of preservative free morphine was injected intrathecally. After several attempts the epidural catheter could not be placed. A T-6 level was obtained and cesarean delivery was accomplished through a supraumbilical vertical incision, due to the patients cellulitis. The patient was comfortable during the procedure. Postoperatively, she was transferred to the intensive care unit for close monitoring of her respiratory status.

Discussion: SO parturients commonly have multiple comorbidities, require extra personnel and special equipment for positioning and transport, frequently require intensive care unit admission postoperatively and are best cared for in tertiary care centers. Ultrasound may not be a clinically useful tool for epidural placement in SO patients due to the increased depth of the epidural space. Spinal anesthesia or CSE anesthesia may be preferred techniques for scheduled cesarean delivery in SO patients due to higher failure rates of epidural catheters. Due to the possibility of unpredictable or exaggerated blocks, it has been suggested that a reduced intrathecal dose be administered with CSE anesthesia in obese patients. This case suggests that SO patients may be prone to difficult epidural catheter placement and incomplete epidural block. Therefore, intrathecal dose reductions may increase the risk of conversion to general anesthesia, putting patients at risk for failed intubation and aspiration.

SOAP 2010