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Management of Accidental Dural Puncture (ADP) complicating Combined Spinal Epidural (CSE) for Caesarean Section (CS) in a patient with severe kyphoscoliosis
Abstract Number: T-78
Abstract Type: Case Report/Case Series
We report successful anaesthetic management for CS in a patient with severe kyphoscoliosis and associated respiratory failure where attempted CSE was complicated by ADP. We could not find a similar case report in the published literature.
A wheel chair bound 36 years old primigravida was planned for a CS at 28 weeks of gestation. She was hospitalized with recurrent chest infections and progressive dyspnea requiring supplemental oxygen for the preceding 4 months. She had corrective surgery for idiopathic kyphoscoliosis 20 years ago, however it continued to deteriorate slowly. Old case notes were not available.
She failed respiratory functions assessment due to dyspnea; cardiology assessment was unremarkable. Chest X-Ray revealed sigmoid shaped tracheal deformity predicting difficult intubation. Cobb’s angle appeared high degree; however the lumbar vertebrae were obscured by the abdominal shield placed to protect the fetus from radiation. Old operation scar extended from upper thoracic to lower lumbar region, with significant lordosis; featuring technical difficulty with RA.
Bedside ultrasound scan revealed lower pole of the Harrington rod at L1-2 interspace, and acoustic windows and good dural signal were noted at L2-3, L3-4 and L4-5.
The patient declined GA, so CSE was planned, with CS under Local Anaesthesia as the backup. A respiratory technician remained present throughout with a CPAP machine to provide respiratory support if needed. Arterial line was inserted, and CSE was attempted with Portex® CSEcure® 18G/27G kit after Ultrasound assisted pre-puncture marking of the skin. ADP occurred; epidural catheter was placed in the subarachanoid space and epidural needle removed, with a view to use it for continuous spinal anaesthesia. The patient was positioned according to her comfort. Fentanyl 15 mcg and small aliquots of Bupivacaine Heavy 0.5% were administered intrathecally (total 20 mg), with careful assessment of block progression to T6 bilaterally.
CS completed uneventfully, intrathecal catheter removed, and patient monitored in ICU. She was discharged home on Day 7. No complications of ADP were noted.
Anaesthetic management for CS with severe kyphoscoliosis and respiratory failure presents unique challenges whereby both Regional Anaesthesia (RA) and General Anaesthesia (GA) are potentially associated with life threatening complications. There is paucity of evidence guiding choice of anaesthetic technique for this scenario. Combined Spinal Epidural (CSE) could potentially offer controlled progression and duration of RA while avoiding hypotension and respiratory morbidity.
CSE may be complicated with ADP; epidural catheter placement in the subarachanoid space may facilitate successful anaesthetic management of patients with severe kyphoscoliosis and respiratory failure.