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Implications of Performing a Combined Spinal-Epidural Technique for Labor Analgesia in a Parturient with Metastatic Lung Adenocarcinoma and Altered Mental Status
Abstract Number: SA-67
Abstract Type: Case Report/Case Series
Neuraxial analgesia is the most effective technique for labor analgesia.1 Case reports have demonstrated permanent neurological injury following neuraxial techniques placed under general anesthesia, 2 so to increase the safety profile, neuraxial analgesia is primarily performed in alert, cooperative parturients. Despite this practice, neuraxial anesthesia is frequently performed under general anesthesia and deemed safe in the pediatric population. 3 We present a woman with mental status changes due to metastatic malignancy in whom neuraxial anesthesia could be provided only with extensive sedation.
This woman was a G2P1001 at 29 weeks who presented to the emergency room with altered mental status and word finding difficulties over the previous two months. Radiographic imaging demonstrated multiple brain lesions found to originate from a poorly differentiated lung adenocarcinoma. MRI suggested no bony involvement in the lumbar spine. Craniotomy was performed nine days after presentation followed by whole brain radiation. On POD 10 she went into preterm labor. She was unable to follow instructions or remain motionless for epidural catheter placement. After discussion with the neurosurgeon, obstetric team and family, regarding her and her family’s wishes and goals of care during labor, the decision was made to perform a CSE using sedation after informed consent. ASA monitors were applied and monitored anesthetic care was provided in the OR with intermittent boluses of propofol 20-30mg (280 mg total). Fetal monitoring was continuous and reassuring throughout placement of the epidural catheter. A CSE was placed without complication in the right lateral decubitus position. Labor analgesia was maintained with a programmed intermittent bolus (bupivacaine 0.1% with fentanyl 2μg/ml 10ml q60 min). A healthy baby girl was born via normal spontaneous vaginal delivery. There were no neurologic sequelae of the technique being performed under sedation.
In our patient, the benefit of neuraxial labor analgesia to reduce suffering and improve her quality of life was of paramount importance to her and her family. Our patient’s limited ability to cooperate and remain motionless during placement of the CSE was safer using sedation than attempting the technique awake. Additionally, potential neurologic damage would be of much smaller long term consequence given her poor disease prognosis. The risk benefit ratio of doing a neuraxial technique under deep sedation may be dramatically altered in patients with metastatic disease whose immediate comfort may outweigh risks of long term sequelae.
1) Anim-Somuah et al. Cochrane Database Sys Rev 2005; CD000331
2) Bromage et al. Reg Anesth Pain Med 1998;23:104-107
3) Krane et al. Reg Anesth Pain Med 1998;23:433-438