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Surgical Anesthesia for Cesarean Delivery Using Transversus Abdominis Plane and Ilioinguinal-Iliohypogastric Blocks
Abstract Number: T-77
Abstract Type: Case Report/Case Series
Introduction: Ultrasound-guided transversus abdominis plane (TAP) and ilioinguinal-iliohypogastric (IIIH) blocks are commonly used for post-cesarean analgesia, but have very rarely been described as the primary anesthetic.(1) We describe the use of ultrasound-guided TAP and IIIH blocks as primary anesthetic for cesarean delivery (CD) in a patient with spinal muscular atrophy (SMA) type II who had relative contraindications to both general and neuraxial anesthesia.
Case: 26 year old G3P2 at 36 weeks gestation presented for repeat CD and bilateral partial salpingectomy via vertical midline incision. Her medical history included SMA type II, severe scoliosis with thoracic and lumbar Harrington Rods, severe restrictive lung disease, and obesity. She strongly desired avoiding general anesthesia given history of a six week period of postoperative intubation and mechanical ventilation due to restrictive lung disease and muscle weakness after her back surgery. Neuraxial anesthesia had not been attempted previously, as she was not judged to be a good candidate given the likelihood of difficulty with patient positioning and block placement in addition to the fact that a surgical block likely would have led to respiratory compromise given her medical history. Two prior CDs were performed using local anesthetic field infiltration by the obstetricians, but the patient reported poor pain control during these procedures. Therefore, we developed an anesthetic plan to perform bilateral ultrasound-guided TAP and IIIH blocks with a sensory level to T10 or higher. This was deemed necessary due to a planned vertical midline incision. Ultrasound-guided TAP and IIIH blocks were completed with 20ml (total) of 0.5% ropivacaine per side. A T8-L1 sensory blockade to pinprick stimuli was confirmed prior to surgery. Sedation was maintained with low dose propofol and ketamine infusions, along with small intermittent fentanyl doses, being careful to maintain spontaneous ventilation. The peritoneum was infiltrated with lidocaine 0.5% by the obstetricians to help minimize visceral discomfort. Delivery of a healthy female infant was uncomplicated and she reported minimal pain both intraoperatively and postoperatively.
Discussion: Patients with SMA type II have a defect of the SMN protein necessary for the survival of motor neurons and commonly experience severe muscle weakness, spinal abnormalities including severe scoliosis, and restrictive lung disease. (reference) Our case presented a unique clinical dilemma because of the relative contraindications to general and neuraxial anesthesia. A 4 patient case series has described the effective use of ultrasound-guided TAP and IIIH blocks for CD as an alternative to local infiltration.(1) We found this unique approach to be effective, and suggest that combined TAP and IIIH blocks along with IV sedation may provide a reasonable alternative anesthetic in select patient cases.
1. Anesth Analg. 2011;113:134-7.