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An Anesthesia Conundrum: Cesarean Section for Twins in Parturient with BMI 86 Refusing Neuraxial Anesthesia
Abstract Number: F1D-7
Abstract Type: Case Report/Case Series
Obesity is a worldwide epidemic. The World Health Organization defines normal weight as a body mass index (BMI) of 18.9-24.9 kg/m2, and obese as BMI > 30 kg/m2. Obese is then further categorized into class I (BMI 30-34.9 kg/m2), class II (BMI 35-39.9 kg/m2) and class III (BMI >40 kg/m2).Not surprising, there is a positive correlation between increasing BMI and increased comorbidities as well as increased complications.
Here we present a case of a 35 year old female G7P3033 with past medical history of chronic hypertension, asthma, gastroesophageal reflux disease, pre-gestational diabetes, obstructive sleep apnea non-compliant with CPAP, and class III obesity (BMI 86.8) for a scheduled repeat Cesarean section for twins at 36 weeks. This combination of comorbidities along with the patient’s non-compliance with medical advice and needle phobia leading to adamant refusal of neuraxial anethesia further complicated her care. Numerous interdisciplinary meetings were held amongst the obstetricians, anesthesiologist, neonatologist, and nursing staff throughout the pregnancy to coordinate her care. Additionally, multiple anesthesia consults with the patient were required to facilitate counseling and reassurance to promote neuraxial anesthesia. Pre-operative ECHO and bilateral lower extremity duplex were unremarkable.
In the holding area, two large bore IVs were inserted and patient was given a non-particulate antacid. In the OR, Standard ASA monitors were placed. 2 units of PRBC and cell saver were on standby. Advanced airway equipment was readily available. Combined spinal-epidural was performed with ketamine sedation. Loss of resistance to air technique was used with loss at 10 cm. 1.2ml of hyperbaric bupivacaine with 25mcg of fentanyl and 0.1mg of preservative-free morphine were used in the spinal. Patient was then laid down on an intubation ramp. A T5 sensory level was achieved. The Cesarean section proceeded uneventfully. Additional 2-3ml aliquots of 2% lidocaine with epinephrine given via epidural as needed. Babys’ APGARS were 7,9 and 8,9 for Baby A and Baby B respectively at 1 and 5 minutes. Estimated blood loss was 1200ml. Post-operative course unremarkable. Patient was discharged home on post-operative day 3 as per standard protocol.
This case highlights the importance of preparation from pre-operative counseling to equipment, positioning, and personnel to the anesthetic itself and airway management.