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Parturient with Benign Intracranial Hypertension and Lumbo-peritoneal shunt for Cesarean delivery: Plan B
Abstract Number: S3D-4
Abstract Type: Case Report/Case Series
Benign intracranial hypertension (BIH) affects women of childbearing age, and may impact both mode of delivery and anesthetic plan. This report describes anesthetic management cesarean delivery in a patient with lumbo-peritoneal (LP) shunt.
A 33 y/o asymptomatic G1P0 with history of BIH with LP shunt presented without prior anesthesia consultation for cesarean delivery. Indication for operative delivery was outside neurologist’s recommendation against labor. A proposal to revisit the necessity for cesarean delivery with the neurologist was declined by the patient. After discussing risks and benefits of multiple plans, the initial plan was for a slowly-dosed epidural placed above the level of the shunt, due to concern about difficulty maintaining a spinal level with shunt, and potential shunt infection. Pre-procedure ultrasound scanning was done to locate interspace above level of shunt. After loss of resistance to saline with Tuohy needle, no blood or CSF was observed, and flexible catheter advanced easily. No CSF was aspirated or flowed back to gravity. However, test dose of 3 mL lidocaine 1.5% with epinephrine resulted in sensory and motor blockade to T6 and hypotension within 5 minutes. Hypotension was treated with phenylephrine, ephedrine and lactated Ringers bolus; fetal heart rate was monitored, and the patient was quickly moved to the operating room to begin the procedure. Thirty minutes after the test dose, during repair of uterine incision, the patient began to report mild discomfort, possibly due to shunting away of the intrathecal lidocaine. After dosing the catheter with 10 mg of lidocaine, the patient was comfortable for the remainder of the procedure. After recovery, symptoms consistent with post-dural puncture headache developed on post-op day 4. Review of literature on blood patch for headache associated with CSF leak after intrathecal pump placement, when the epidural space may be attenuated, suggests lower efficacy than that seen in obstetrics. Given this information, the patient was offered consultation with the radiology department for possible blood patch under imaging, but declined. Her headache resolved spontaneously over the following week.
As there are multiple reports of patients with BIH delivering vaginally, a pre-op anesthesia consultation would have allowed for multidisciplinary discussion about need for cesarean delivery. Although effort was made to avoid site of prior procedure, the epidural space at the chosen level may have been obliterated, contributing to the intrathecal catheter. Regardless of mode of delivery, the anesthesia team as well as the patient must be prepared to modify plans as required by peri-procedural events.
Ref.: Kaul B, Vallejo MC, Ramanathan S et al. Accidental spinal analgesia in the presence of a lumboperitoneal shunt in an obese parturient receiving enoxaparin therapy. Anesth Analg. 2002; 95:441-3.