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Dual neuroaxial catheter placement for a super morbidly obese parturient undergoing cesarean section
Abstract Number: T-11
Abstract Type: Case Report/Case Series
Super Morbid Obesity is classified as a BMI > 50 Kg/m2. These patients present special challenges for the anesthesia provider.
A 35 y/o G4 P1 presented at 39 weeks for an elective repeat C/S and BTL. Her BMI was 80.3 Kg/m2 classifying her as super morbidly obese. Her prior C/S was performed under GETA and complicated by a wound infection. The remainder of her history was benign except for well-controlled GERD.
A dual neuraxial anesthetic technique to include a thoracic epidural catheter for post-op pain control and lumbar dural puncture and placement of a spinal catheter for intraoperative anesthesia was planned. Our pre-anesthetic assessment was notable for an unfavorable airway, large pannus and potentially difficult peripheral IV access, therefore in the pre-op area we placed 2 large bore PIV's and an arterial line under ultrasound guidance (USG).
The patient was then taken to the OR and assisted to a sitting position using an epidural positioning device. Tape was applied to both sides of her back retracting tissue to allow landmarks to be identified with USG. A thoracic epidural was placed at the T10/11 level using a 9cm touhy needle, LOR was obtained at 9cm after several attempts.
The back was re-prepped and a lumbar intrathecal catheter was introduced at L3/4 after obtaining CSF at 11cm with a Gertie Marx 5” CSE needle. The spinal catheter was dosed with approximately half of our standard dose (6mg 0.75% Bupivacaine with Dextrose, 7.5 mcg Fentanyl and 75 mcg of preservative free Morphine). 
The patient was assisted to the lateral position and the catheters were secured with tegaderm.  A bilateral T4 level was obtained. A MAP of 80 mm Hg was maintained with phenylephrine boluses. The C/S was uneventful but due to a large hernia repair, the surgery lasted 7 hours. The lumbar catheter was re-dosed as needed and the patient tolerated the surgery well.
Postoperative pain control was obtained with an infusion of 0.2% Ropivacaine via the thoracic epidural. The patient spent 24 hours recovering on the L&D unit for close monitoring and was discharged home on PPD 4 with no complications.
A dual catheter technique worked well for our 218Kg patient. The spinal catheter provided a reliable and predictable black especially important when surgery was unexpectedly prolonged.
1. Current opinion in Anesthesiology, 2009. 22:683-686
2. Acta Anasthesiol Scand 2008;52;6-19