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Neuroaxial anestheisa in obstetric patient with congenital insensitivity to pain
Abstract Number: T-67
Abstract Type: Case Report/Case Series
Introduction: Congenital insensitivity to pain (CIP) is a group of rare genetic disorders characterized by varying degrees of sensory loss including nociceptive hyposensitivity and varying degrees of autonomic dysfunction1. It can be further categorized into five different types of hereditary sensory and autonomic neuropathies (HSANs I-V) 2. This case report describes the anesthetic management of a parturient with congenital insensitivity to pain presenting for cesarean delivery.
Case report: A 27-year-old G3T1P1A0L2 pregnant female at 32 weeks gestation with a past medical history of CIP presented to obstetric anesthesia clinic for assessment for her upcoming elective cesarean section. Her two previous deliveries were complicated because the patient was unaware of her labor. The decision was made to schedule her for cesarean section at 39 weeks to avoid this from occurring again. She denied symptoms of gastroesophygeal reflux. She described multiple injuries in the past, including a fractured tibia as a child that she was unaware of. She ha previously undergone general anesthetic without difficulties. Her physical findings showed that temperature sensation was preserved throughout all dermatomes, although sharp touch distinction was not appreciated. With respect to anesthetic technique, the patient was given the option between general anesthesia and neuraxial anesthesia. The patient was advised that a neuraxial technique for cesarean section in a patient with CIP had not previously been described in the literature. The patient requested spinal anesthesia for delivery. On the day of surgery, no local anesthetic was injected prior to insertion of a 20 Gauge introducer needle. Insertion of the needle did not provoke pain. A 25 Gauge Whitacre needle was used to locate the intrathecal space on the first attempt. 10.5 mg of 0.75% Bupivicaine was injected intrathecally. The level of neuraxial blockade was assessed by two modalities: temperature and fine touch. The block was estimated to be at the T4 level bilaterally according to loss of temperature sensation. The patient was unable to delineate the loss of fine touch sensation. Her blood pressure remained stable. The remainder of the anesthetic care was uneventful.
Discussion: CIPA and the spectrum of HSAN disorders present numerous challenges to the anesthesiologist. Although our patient underwent neuraxial anesthesia for caesarean delivery and experienced no complications, there are many important anesthetic considerations to be aware of when formulating an anesthetic plan. We recommend a thorough a perioperative evaluation, as HSAN patients experience different degrees of pain perception and sensation. Anesthetic considerations must also include potential hemodynamic instability secondary to autonomic dysfunction, prevention of aspiration, and maintenance of body temperature.
1. Weingarten TN et al. Anesthesiology. 2006;105:338-345.
2. Parrott . AANA Journal. 2013, 81:5