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Sequential Spinal for a Cesarean Delivery in a Patient with Aortic Stenosis
Abstract Number: T-70
Abstract Type: Case Report/Case Series
Spinal anesthesia for cesarean delivery is usually contraindicated in aortic stenosis due to concerns for hemodynamic instability (1). We report a case where a spinal anesthetic was dosed sequentially in a patient with moderate aortic stenosis with minimal hemodynamic changes.
A 36 year-old primigravida with known congenital aortic stenosis and dilated aortic root presented for elective cesarean delivery at 37 6/7 weeks gestation. The patient noted a history of being “resistant to local anesthetics” as she always required more local anesthetic at dental visits. Her preoperative transthoracic echocardiogram (TTE) demonstrated an ejection fraction of 60-65% with a mean aortic gradient of 46mmHg and a peak of 80 mmHg.
On the day of surgery, after an arterial line and an 18-gauge IV were placed, an epidural catheter was easily placed after dural puncture confirmed cerebrospinal fluid (CSF) (dural puncture epidural) but no spinal medication was administered. A total of 27 ml 2% lidocaine was administered in divided doses with only a patchy T12 level and minimal motor block obtained. A combined spinal-epidural (CSE) procedure was then performed, with 1.25 mg isobaric bupivacaine and 0.2 mg morphine given spinally. After dosing 10 ml 2% lidocaine epidurally, an adequate level of anesthesia still could not be obtained. After extensive discussion with the patient, we decided to attempt a sequential spinal in the right lateral decubitus position. Free flow of CSF was confirmed with a 25G Whitacre needle and incremental, sequential doses of 0.4 ml 0.75% hyperbaric (3 mg) bupivacaine were given through the spinal needle. A total of 12mg was given over the course of 15 minutes as the patient remained in the lateral position with the spinal needle in place. A phenylephrine infusion was titrated to maintain arterial pressure near baseline. Another provider tested the level of anesthesia to pinprick bilaterally at frequent intervals to monitor the rise of the anesthetic level to T4. Once a good surgical level was achieved, the Whitacre needle was removed, and the patient was placed supine with left tilt.
The surgery proceeded uneventfully. The baby was delivered with Apgars of 9 and 9, and the patient did not develop a dural puncture headache.
This case demonstrates that a spinal anesthetic for cesarean delivery is possible and can be done safely in a patient with moderate to severe aortic stenosis when appropriate preoperative, intraoperative, and postoperative management is used. A continuous spinal anesthetic using a catheter technique could have been chosen (2), but that would have necessitated the puncture of the dura and arachnoid with a much larger needle than a 25G Whitacre, increasing the risk of a post-dural puncture headache.
1. IJOA 2009; 18:379-86
2. BJA 2001; 86: 723-6