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///2015 Abstract Details
2015 Abstract Details2019-08-02T16:54:43-05:00

Dual neuroaxial catheter placement for a super morbidly obese parturient undergoing cesarean section

Abstract Number: T-11
Abstract Type: Case Report/Case Series

Brian J Cocchiola MD1 ; Fatoumata Kromah MD2; Jamie P Graham MSNA3

Introduction

Super Morbid Obesity is classified as a BMI > 50 Kg/m2. These patients present special challenges for the anesthesia provider.

Case Report

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). [1]

The patient was assisted to the lateral position and the catheters were secured with tegaderm. [2] 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.

Discussion

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.

References

1. Current opinion in Anesthesiology, 2009. 22:683-686

2. Acta Anasthesiol Scand 2008;52;6-19



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