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Anesthetic Management of a Pregnant Patient with Poly Trauma for Spine Surgery
Abstract Number: F-55
Abstract Type: Case Report/Case Series
A previously healthy 32 year old female presented while 17 weeks pregnant as a trauma following a motor vehicle collision. Her multiple injuries included a grade II liver laceration, bilateral (b/l) clavicular fractures, C1 transverse process fracture, T11 vertebral body burst fracture, multiple b/l rib fractures, b/l small pneumothoraces and right pulmonary contusion. Preoperatively, she required 2-3 liters of oxygen and had trouble clearing her secretions. Chest X-ray demonstrated complete collapse of the left lung. Because of the unstable spine fracture, it was decided to perform a posterior T9-L1 fusion under general anesthesia. General endotracheal anesthesia was induced without complication. Following intubation, bronchoscopy was performed to suction the airway given her preoperative X-ray. The radial artery was cannulated for hemodynamic monitoring. She was then positioned prone on an open frame Jackson table. Care was taken to avoid direct compression of the fetus and the abdomen. Fluoroscopy was limited to only essential parts of the procedure. Anesthesia was maintained with propofol and remifentanyl infusions and sevoflurane to facilitate neurologic monitoring. She remained hemodynamically stable throughout the procedure and was successfully extubated. She was subsequently discharged and delivered a healthy baby at term.
The anesthetic considerations of this case were many. This G1P0 patient required spine fixation surgery in the prone position. The gestational age of the fetus as well as the acute maternal injuries were taken into account. At 17 weeks gestation, delivery of the fetus was not a feasible option. Fetal heart tones were monitored and remained within normal limits pre and post operatively. Concerns about anesthetic effects on the developing human fetus have been considered, but there is no convincing evidence that any particular anesthetic drug is dangerous to the fetus. Anesthetic goals are to prevent fetal asphyxia by maintaining maternal oxygenation, ventilation and hemodynamic stability(1). As this patient had small pneumothoraces, there was concern for expanding, and even perhaps creating a tension pneumothorax with positive pressure ventilation. As such, she was ventilated with small tidal volumes and special attention was paid to peak airway pressures and plethysmography. Additionally, the general surgery team was made aware of the patient, and a chest tube kit was in the room. The management of an occult or clinically insignificant pneumothorax in acute trauma patients is debatable. There appears to be a growing recognition small that pneumothorax can be safely treated without placing a thoracostomy tube in even mechanically ventilated patients. Successful surgical intervention was performed with good maternal and fetal outcome due to thorough systematic assessment of individual issue and stratification of management priorities.
1. Reitman E., et al. Br. J. Anaesth. 2011: 107 (suppl 1).