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Anesthetic management of super morbidly obese parturients for cesarean section using a double neuraxial catheter technique: A case series
Abstract Number: S-08
Abstract Type: Case Report/Case Series
Parturients with a body mass index greater than 50 kg/m² (super morbid obesity) represent a growing segment of the patients that require anesthetic care for labor and delivery. Severe obesity and its comorbid conditions place the parturient and her fetus at greater risk for pregnancy complications and cesarean delivery, as well as surgical and anesthetic complications.
The surgical approach for cesarean delivery in these patients may require a supraumbilical vertical midline incision due to a large pannus. The dense, T4-level of spinal anesthesia can cause difficulties with ventilation for the obese patient during the procedure, which can be long in duration. Patients may also have respiratory complications in the post-operative period due to pain at the high incision.
The use of 2 epidural catheters (low thoracic and lumbar) in a super morbidly obese parturient was previously reported by McDonnell and Paech, but we are not aware of any reports of continuous spinal and epidural catheters in this population.
We describe the anesthetic management of three parturients with BMI = 77, 81 and 96 kg/m² that required cesarean delivery via a supraumbilical vertical midline incision. Continuous lumbar spinal and low thoracic epidural catheters were placed in each patient for intraoperative anesthesia and post-operative analgesia, respectively. Ultrasound guidance was used to help identify landmarks.
The patients were positioned on the operating table using an air-assisted patient transfer mat in a semi-recumbent position with the head of the bed elevated 45 degrees to allow for greater patient comfort and improved ventilatory mechanics. The spinal catheter was dosed incrementally with bupivacaine titrated slowly to a T4 anesthetic level. All patients had continuous blood pressure monitoring using a radial arterial catheter. One patient with severe sleep apnea required BiPAP during the procedure.
All three patients were monitored post-operatively in the surgical intensive care unit, and received multi-modal analgesia including a thoracic epidural infusion of bupivacaine 0.125% and fentanyl 2 mcg/ml, as well as intrathecal morphine (150 mcg) to achieve adequate post-operative pain control. Spinal catheters were removed after 24 hours to reduce the risk of post-dural puncture headache. Patients were followed for 7 days post-operatively, and none suffered a post-dural puncture headache.
A continuous spinal catheter offers several advantages in the anesthetic management of super morbidly obese parturients for cesarean section. It allows for a dense, reliable block that can be titrated slowly to the desired level while monitoring the patient’s respiratory status and can be redosed as needed throughout the case. In addition, a low thoracic epidural can be helpful to adequately manage post-operative pain and prevent respiratory complications related to splinting.
Anaesth Intensive Care (2007) 35(6): 979-983.