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Cesarean delivery under general anesthesia with TAP catheters for post-operative analgesia in a patient with osteogenesis imperfecta
Abstract Number: F-32
Abstract Type: Case Report/Case Series
We present a case of a 37 yo G1P0 African American with OI type III or IV, weighing 36 kgs and 111cm, with a history of over 100 fractures, a known difficult airway, kyphoscoliosis, a basilar invagination with an upward migration of C2 causing narrowing of the foramen magnum and pressure on the brainstem, and hip and back pain. On fetal ultrasound, there was no shortening of long bones or ribs indicating the fetus was not affected by OI. The patient was admitted at 26 weeks gestation for worsening respiratory status and decision was made to proceed with a Cesarean delivery at 32 weeks. She was placed on BiPAP at night for comfort. Due to concerns related to the severe kyphoscoliosis with respiratory compromise and the patients’ preference, general anesthesia (GA) with an awake fiberoptic intubation was decided. Premedication included glycopyrrolate, midazolam (2mg) and sodium bicitra and topical lidocaine. Two IV lines and an arterial line were placed. The patient was sedated with remifentanil (0.05mcg/kg) and propofol (10mg). Several unsuccessful attempts at fiberoptic intubation resulted in inducing GA (rocuronium 35mg, propofol 20mg) and she was intubated with some difficulty with a Glidescope with a size 3 blade. A senior ENT resident was present in the operating room during the course of airway management. The Cesarean delivery proceeded without difficulty through midline abdominal and low transverse uterine incisions. Anesthesia was maintained with N2O and sevoflurane until delivery of a baby boy (1,979kg, 43cm), and then switched to remifentanil and propofol after delivery; reversal with neostigmine 1.8mg and glycopyrrolate 0.3mg at the end of the case. Bilateral transversus abdominis plane (TAP) catheters were placed for post-op analgesia (1). She was extubated to BiPAP in the ICU within 4h. Her remaining recovery was uneventful. TAP catheters were kept for 48h, with boluses on each side every 8h (bupivacaine 0.375% 10ml/side) with good pain relief.
OI is a congenital disease most often caused by a defect in the gene that produces type-1 collagen. Cesarean deliveries in OI patients have been reported under GA or CSE (2). We opted for a GA due to the severe kyphoscoliosis in anticipation that the patient would not tolerate a regional anesthetic block to T4 without worsening her already impaired respiratory mechanics. TAP catheters for post-op analgesia proved extremely beneficial as well.
1. Bollag, IJOA 2011
2. Murray, IJOA 2010