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Clinical Experience with a Cesarean Section for a Patient with Extreme Morbid Obesity ; Utilization of an Intrathecal Catheter and Surgical Transversus Abdominis Plane Block with Wound Closure by Applying a Negative Pressure Vacuum-Assisted Closure Device
Abstract Number: SA-75
Abstract Type: Case Report/Case Series
A 35 year old woman G2P0 was admitted for an elective primary caesarean section at 38 weeks and 6 days. Her BMI on admission for C-Section was 90. Other comorbidities included chronic hypertension, diabetes, and obstructive sleep apnea. On the day prior to the surgery, she obtained an IR guided peripheral vascular access. Continuous spinal anesthesia was planned secondary to extreme morbid obesity. Her epidural space was identified at 9cm in a seated position with an ultrasound guidance, and the needle was advanced further until clear CSF was seen flowing back. A 20G intrathecal catheter was placed into the L3-L4 interspace with a total of 5 cm left inside the space. A T6 sensory block was achieved with 0.5ml of 0.75% hyperbaric bupivacaine followed by additional 15 microgram of fentanyl intrathecally. The surgical approach involved the use of a vertical midline incision that was located below the level of the umbilicus, followed by uneventful cesarean delivery. Surgical duration was approximately 2 hours and 10 minutes. A total of 2L of crystalloid fluid was administered, and total blood loss was estimated about 800 ml. For the postoperative pain control, 200 mcg of preservative free morphine was administered intrathecally after delivery, and a transversus abdominis plane (TAP) block was performed with a total 20 milliliters of 0.75% Ropivacaine bilaterally by the surgeon. To prevent wound complication, a negative pressure wound management system was applied by the surgeon during wound closure. She was given IV/PO acetaminophen 1000mg every 8 hours and IV ketorolac 30 mg every 6 hours for 36 hours postoperatively, and discharged home on postoperative day 2 with her baby without any complication.
The advantage of an intrathecal catheter includes that there is a continuous and tested means of providing adequate surgical anesthesia, and the blockade can also be reliably extended. Our choice is similar to that made by Polin et al in their case series of three super morbidly obese patients who underwent caesarean delivery. In our case the patient’s incision was vertical which allowed us to use a TAP block successfully by the surgeon during wound closure. A unique aspect of the wound management in this patient is the use of a negative pressure wound management system due to the attendant risk of compromised wound healing. In an obese parturient careful planning for labor and delivery should be undertaken to ensure that they are able to deliver safely.
Polin CM, Hale B, Mauritz AA, Habib AS, Jones CA, Strouch ZY, Dominguez JE. Anesthetic management of super-morbidly obese parturients for cesarean delivery with a double neuraxial catheter technique: a case series. Int J Obstet Anesth. 2015 Aug;24(3):276-80.
Scherer SS, Pietramaggiori G, Mathews JC, Prsa MJ, Huang S, Orgill DP. The mechanism of action of the vacuum-assisted closure device. Plastic and reconstructive surgery. 2008 Sep 1;122(3):786-97.