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Anesthesia management of a parturient with pulmonary Kaposi Sarcoma and AIDS
Abstract Number: T-07
Abstract Type: Case Report/Case Series
This is a 30 yo g2p1, EGA 33 weeks woman presented to us with non-reassuring fetal heart rate therefore an urgent C-section was called. The patient’s history was significant for AIDS with pulmonary Kaposi Sarcoma (KS), bilateral pleural effusion (multiple thoracentesis) and severe right lung infiltration. She developed fever, dyspnea the day before and was diagnosed with influenza and on OSELTAMIVIR. The respiratory distress got worse on the day of cesarean and the patient could only tolerate the sitting position. Her CXR showed complete opacification on the left hemithorax (pleural effusion) and increased infiltration on the right. Anesthesia preop examination revealed a diaphoretic, frail woman in considerable respiratory distress. She had difficulty to talk due to severe tachypnea. There were diffuse rales and crackles and decreased breath sound on left side. Oxygen saturation was above 90% on face mask oxygenation. Her respiratory function was near failure and clearly required mechanical ventilation. General anesthesia was discussed with the patient. However, the patient had a strong desire to have spinal anesthesia and refused general anesthesia due to the fear that she might never wake up again. A team meeting between obstetric and the anesthesia teams had approached a plan to grant the patient’s wish. We placed combined spinal-epidural anesthesia and the obstetricians were able to operate with the patient in a semi-sitting position. The patient did relative well intraoperatively with T6 level and her symptom was slightly improved during immediate postpartum in the OR. The patient expressed her appreciation of our efforts and was extreme happy to be able to see her baby. Patient was transported to ICU and her condition worsened on the post-op day 3 when she developed respiratory failure and eventually agreed to be intubated, but refused chest compression. She soon developed multiple organ failure and on the post-op day 8 her family decided to withdraw her life-support and the patient passed away.
First, respect the patient’s autonomy. This patient’s condition clearly required ventilator. However, with her end-stage AIDS and her desire to be awake, we planned well with obstetric team and earned the patient’s satisfaction. Second, spinal anesthesia for the patient with respiratory failure is a challenge. Balance has to make to provide adequate block without further impairment of respiratory function. Last, airway obstructions exist in some patients with KS (1). Bronchoscopy of our patient showed many “heaped up” lesions on the airway walls. From this case we also learned the KS in pregnant women with AIDS has an aggressive clinical course, with high rates of visceral involvement and decreased survival (2). We will provide the complete data and the figures for this case at the SOAP meeting in May 2014.
1. Lawson G. B. ENT. 2010; 6(4):285-8.
2. Pantanowitz L. et al. Am J Perinatol. 2005; 22(8):457.