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Cesarean hysterectomy and spinal catheter: when single shot spinal is not the best option.
Abstract Number: F-68
Abstract Type: Case Report/Case Series
Use of intrathecal catheters dates back to 1944, when Edward B. Tuohy proposed modification of the hypodermic needle for placement of intrathecal catheters(1,2). It combines deep neuraxial block of spinal anesthesia with the benefits of incremental dosing. After initial failed attempts at spinal micro catheters (3), continuous spinal techniques have recently been performed with an epidural macro catheter, with its increased PDPH risk. With re-introduction to the market of over the needle smaller spinal micro catheters this technique has been revisited for use in cases with the anticipation of prolonged surgical procedures (4). We report a C-section case and cesarean hysterectomy due to placenta accreta, performed using continuous spinal technique. Case: A 37 week G3P1 parturient with history of endometrial ablations, diagnosed posterior marginal placenta previa with a reported risk of placenta accreta, presented for elective C-section. A spinal micro catheter was placed without issue (23G, catheter over needle method) due to an anticipated long surgical duration. The patient reported no paresthesia, and easy flow of CSF was obtained. 0.25% isobaric bupivacaine was administered in incremental boluses to achieve a level of surgical anesthesia (T6) and cesarean section was performed. Slow incremental installation of block provided hemodynamic parameter stability during onset and duration of the spinal anesthesia. After delivery of healthy baby, a placenta accreta was diagnosed by the obstetric team and a cesarean hysterectomy was performed. Estimated blood loss of 1400 ml treated with 1 unit of packed red cells transfused intraoperatively along with 3 L of crystalloids. Use of vasopressor drugs was not required during the case with patient maintaining blood pressures between 120-140/60-80 mmHg and heart rate of 60-90 bpm with 2 short episodes of 100 bpm, which resolved without the need for further intervention spontaneously. Patient had no complications in postoperative period uneventful recovery, and was satisfied with comfort level that spinal anesthesia provided.
Discussion: Case series have been reported with the over the needle spinal catheter in labor (4), but none to date for use in a case of cesarean hysterectomy. There are no detailed reports of the incidence of technical difficulty, postural puncture headache or paresthesia with this technique, except a single report of transient paresthesia (4). There is a learning curve when using any new technique, but with a smaller dural puncture by the spinal micro catheter, one may expect a lower incidence of post operative issues. This technique can be considered when a long or complicated surgical duration is expected.
1 Tuohy EB. Anesthesiology 1944;5:142
2 Frolich MA et al. Anesth Analg 2001; 93: 215
3 Rigler ML et al. Anesth Analg 1991;72:275
4 Tao W et al. Int J Obstet Anesth 2011;20:351