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MARFAN'S SYNDROME AND NEUROAXIAL ANESTHESIA FOR CESAREAN SECTION
Abstract Number: T 73
Abstract Type: Case Report/Case Series
Introduction: Marfan’s syndrome (MFS) is an autosomal dominant trait with a reported incidence of 1:3000 to 1:5000 individuals. We report a patient with MFS who received anesthesia for three pregnancies.
Case Report: A 37 year old G3 P2012 with Marfan’s syndrome presented for elective repeat C/S and BTL in 2012. Vital signs: Ht 5”7” Wt 160lbs BP 100/60 P79 Hct 36, platelets 153, Creatinine 0.8 Cardiac echo unchanged. Medications: betablockers. Allergy to latex. In 2002, she had a modified “elephant” procedure for aortic aneurysm repair. In 2007, spinal was used for primary C/S for breech. It required 3 spinals to achieve surgical level after 45 minutes. Spinal resolved within two hours. In 2009 repeat C/S, a total of 200mgs of 5% hyperbaric lidocaine and 15mgs of spinal 0.75% bupivacaine was required to achieve a T4 level over 50 minutes. Recovery from the spinal was complete in two hours. Postoperatively, the serum creatinine rose from 1.6 to 2.8. Ketoralac and ibuprophen were suspected since the level normalized when they were discontinued. The patient did have theMRI done. Epidural anesthesia was initiated in the PACU and 25mls of 2% lidocaine with epinephrine and sodium bicarbonate was injected through the epidural needle in 5mls increments every 5 minutes. The epidural catheter was inserted but no level was detected for 30 minutes when the patient reported warmth in her right foot. Additional 10 mls of lidocaine was administered at 5 minute intervals and a T6 level was achieved 30 minutes later. She was brought to the OR where 10mls of lidocaine and 100 mcg fentanyl were given to solidify a T4 level. Repeat C/S and BTL proceeded uneventfully. The baby had Apgars of 9 and 9. Morphine 3 mgs was given with 10mls of 0.25% bupivacaine for postop analgesia.
Discussion: The patient most likely has ductal ectasia since 60 to 90% of patients with MFS have it. This will explain why she a lot more anesthetic to achieve a surgical level. Local anesthetic resistance cannot be excluded since it took 45 to 60 minutes to achieve any level. There might, in addition, be local anesthetic resistance in this patient since it took 45 to 50 minutes to get a level with spinal. We are still trying to persuade the patient to have an MRI since her father, sister and first child have MFS and it might help future anesthesia providers to definitely know if ductal ectasia exists in this family.