Spinal Anesthesia in Fowler Position
Abstract Number: F-54
Abstract Type: Case Report/Case Series
26 year old gravida-1-para-0 full term pregnant patient was admitted to labor-delivery suite; her body mass index was 35. She underwent epidural placement for labor analgesia. Epidural catheter provided good analgesia during labor. Twelve hours later, she was taken to operation room for cesarean section: indication was prolonged rupture of membranes and arrest of cervical dilatation. Epidural space was bolused with 600mg chloroprocaine for surgical anesthesia. However, onset of anesthesia was delayed and potential migration of epidural catheter was suspected. As incision site had already been surgically cleaned and draped, decision was made to remove non-functioning epidural catheter and attempt spinal anesthesia in Fowler position (Schematic Figure 1) to avoid difficult airway. The anesthesia screen was slightly advanced towards the foot-end of operation room table. The patient was asked to fold her arms in front of her chest and raise her torso 40° from the table without bending her knees. Her shoulder blades were comfortably supported by the assisting anesthesia personnel so that her head did not cross across the anesthesia screen and did not contaminate the sterile surgical field. Subsequently, back of the operation room table was inclined downwards 50° so that angle between the raised patient's torso and the operating room table's back remained perpendicular. Henceforth, the kneeling anesthesiologist successfully performed spinal anesthesia with 12mg bupivacaine with his hands resting comfortably on the table and the direction of spinal puncture needle perpendicular to patient's skin and parallel to operating room table's inclined back. The comfort levels of patient, operating anesthesiologist and assisting anesthesia providers were adequate. This case report highlights that there is feasibility for conversion of failed epidural/spinal into successful spinal anesthesia in a non-urgent cesarean section wherein a non-obese patient has been surgically cleaned and draped before testing for onset of surgical anesthesia. Moreover, successful spinal puncture is possible in Fowler position: we have independently observed that Fowler position increases interlaminar distances per lumbar ultrasound examination. Finally, technique of spinal puncture in Fowler position may be an opportunity to deliver single dose intrathecal analgesics in prolonged second stage of labor secondary to the pain-inhibited-pushing despite complete cervical dilatation and effacement.