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Severe Uncorrected Kyphoscoliosis in a Pregnant Patient. Decision Making and Anesthetic Management of Cesarean Delivery
Abstract Number: T 75
Abstract Type: Case Report/Case Series
INTRODUCTION: We present the decision-making and anesthetic management of a pregnant patient with severe kyphoscoliotic deformity.
CASE: A 36 yo G1P0 Filipino woman with a history of asthma and severe, uncorrected kyphoscoliosis was admitted to antepartum with shortness of breath. She was 132 cm tall and 45 kg. ABG on RA revealed pH 7.40/pCO2 50/HCO3 30/pO2 51.
The patient’s chin was touching her chest, and her shoulders were at the level of her ears. Neck extension was fair; MP 3. Chest auscultation revealed bilateral wheezes. ECHO was nl with PA systolic pressure 25 mmHg and LVEF 58%. Spirometry showed a severe restrictive pattern, with FVC 0.70 (35% predicted); FEV1 0.52 L (28% predicted); FEV1/FVC 75%.
CT of the airway was read as widely patent (CT attached). However, immediately below the cricothyroid cartilage, the trachea deviated posteriorly at a significant angle, only to then deviate a second time at a nearly 90o angle caudally. Concern was expressed that even if the trachea could be orally intubated, or a tracheostomy could be performed at the level of the cricothyroid membrane, that positive pressure ventilation past the 90o bend would be problematic.
At 26 weeks the patient’s O2 requirement increased from 1 to 2 L/min. ABG revealed a pH 7.33 and pCO2 that was increased at 52 mmHg. Concerns were balanced between the fetal consequences of early delivery and the effect of the increasing uterine size on the patient’s severe restrictive lung disease. Induction of labor was considered, but was believed unlikely to be well tolerated. The decision was made to perform a scheduled CD at 27 weeks gestation with ENT present. General anesthesia was rejected because of intubation and ventilation concerns above. Epidural anesthesia was chosen because of controllable onset. The catheter was placed without difficulty, and a bilateral T4 level was achieved. A 1065g male infant was delivered by classical CD with APGARS 5 & 6. The patient was transferred to the ICU in stable condition and left the hospital four days after delivery on home O2 therapy.
DISCUSSION: The success rate for epidural anesthesia in uncorrected scoliosis is 80%. We experienced none of the reported problems in this population, including placement difficulty, asymmetric, patchy or unilateral block. The care of this unusual patient brought together a multidisciplinary team that determined a safe time and method of delivery, leading to a successful outcome.