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Management of a Parturient with Acute Respiratory Distress Failure with Spinal Anesthesia for Cesarean Delivery
Abstract Number: F 54
Abstract Type: Case Report/Case Series
Acute Respiratory Distress Syndrome (ARDS) is a rare presentation in parturients(1). We present a successful use of spinal anesthesia on a preterm parturient with severe preeclampsia and ARDS. There have been very limited data available on the use of spinal anesthesia on pregnant patients with ARDS.
A 27 year old female G1P0 at 29 weeks of gestation (BMI 29 kg/m2) was admitted to the antepartum unit with a productive cough and hypertension. Her blood pressure was 160/110 mmHg. Physical examination was otherwise normal. Work up showed WBC of 14.1k/uL and proteinuria 0.69g/day. All other labs were normal. Chest X-ray after informed consent showed a left lower lung infiltrate. The patient was given labetalol, azithromycin, ceftriaxone, and betamethasone in anticipation of preterm delivery. Over two days, her cough worsened and she developed dyspnea. She was given oxygen by face mask to maintain SpO2 in the 90s. Her chest X-ray showed progression of left lower lung infiltrates. The decision was made to do an emergency cesarean delivery in view of severe preeclampsia and worsening pneumonia. Her SpO2 was 74% on room air, and in the 90s with non-rebreathing face mask. BP was 171/124 mmHg. After considering the risks associated with general anesthesia, we proceeded with spinal anesthesia with epidural catheter placement. The patient was instructed on deep breathing, and we planned to use Non-Invasive Mechanical Ventilation (NIMV) during surgery, if needed. Spinal anesthesia was given with 40mg Lidocaine 2%, 100mcg epinephrine, and 25mcg fentanyl, achieving an anesthetic level of T6. She maintained SpO2 in the 90s throughout the procedure. A healthy baby was delivered, and the mother was transferred to the ICU for further management. Postoperative chest X-ray showed bilateral pulmonary opacities. Echocardiogram was normal. She was started on NIMV and antibiotics. Magnesium sulfate was administered for 24 hours. The patient was weaned off NIMV over two days and was transferred to the floor on post-operative day 7.
We decided to administer spinal anesthesia to avoid the complications related to general anesthesia: difficult airway with low O2 reserve, aspiration, decreased FRC, and hemodynamic changes with severe preeclampsia. Erdogan, et al have demonstrated the use of spinal anesthesia with NIMV in a patient with pulmonary edema for cesarean delivery(2). Since spinal anesthesia can also affect respiratory reserve, we decided to use low dose lidocaine and administer epidural anesthesia if needed. Our patient was cooperative with the deep breathing and did not require NIMV intraoperatively.
1) Catanzarite, et al ARDS in pregnancy and the puerperium: Causes, courses, and outcome. Obstet Gynecol 2001; 97:760.
2) Erdogan, et al Non-invasive mechanical ventilation with spinal anesthesia for Cesarean delivery. Int J Obstet Anesth 2010 Oct; 19(4):438.