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Cesarean section anesthetic management for a parturient with ESRD
Abstract Number: S2D-6
Abstract Type: Case Report/Case Series
Introduction: With advances in medicine over the years, there is an increasing number of women with ESRD who can conceive and carry their pregnancy through delivery. This population remains challenging to manage for anesthesiologists. Here we describe the management of a complex ESRD patient undergoing C-section.
Case: A 37 y.o. (120 kg 155 cm) G4P0 AAF at 32w4d with PMHx of cHTN, OSA, h/o CVA 4 mo prior with residual R sided weakness, supermorbid obesity (BMI 50), DM1, and ESRD presented with elevated BP above baseline (SBP>30 mmHg increase). She later developed worsening BP increases (SBP as high as 50 mmHg above baseline) in addition to rising liver enzyme labs (>2x normal) and thus met criteria for pre-eclampsia with severe features, prompting emergent delivery.
The patient had a hypercoagulable state with negative hematology workup for pre-existing disease, including APLS testing. She was on aspirin 81 mg po qday and heparin 5000U sc bid. PT and PTT were normal but fibrinogen high at 841. K+ was 5.4 mEq/dL. The patient later mentioned that she drank OJ 15 min prior to going to OR. She appeared normovolemic and did not exhibit signs of uremia. Airway exam revealed MP3 and small mouth opening.
We proceeded with a neuraxial approach, attempting both spinal and epidural. Despite multiple approaches and use of US, neuraxial anesthetic was unsuccessful. For GA, RSI with propofol and rocuronium was done with video laryngoscopy and case proceeded uneventfully. At the end, 0/4 twitches present, and decision made to sedate patient and monitor in ICU. Patient was extubated several hours later.
Discussion: ESRD patients have impaired drug clearance and metabolite accumulation which can lead to adverse events. These patients may also have altered platelet function. However, in pregnancy, certain coagulation factors are elevated. This patient was overall hypercoagulable and we determined risk of spinal or epidural hematoma to be low. We deemed neuraxial to be optimal due to concerns with securing airway safely.
Our hand was forced into GA due to unsuccessful neuraxial. Succinylcholine was avoided due to the elevated K+ and recent stroke, so rocuronium was used. We predicted that residual paralysis would be likely. Reversal with neostigmine was not done due to potential recurarization. Sugammadex was not used due to insufficient safety data in ESRD.
Many considerations exist for ESRD parturients. Fluid status must be determined and hypertension must be controlled. A neuraxial approach is preferred by most to avoid issues with systemic drug clearance and potential aspiration with GA but providers must remain vigilant regarding platelet dysfunction. Neuraxial anesthesia has been reported to be safe with a normal coagulation profile. If systemic opioid or paralytic is given, prolonged duration must be anticipated. Ultimately, both general and neuraxial anesthesia can be used safely but the risk-benefit ratio must be determined for each patient.