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///2018 Abstract Details
2018 Abstract Details2019-08-02T15:57:01-05:00

Peripartum Anesthetic Management of a Spinal Muscular Atrophy (SMA) Type II Patient with TIVA and Bilateral TAP Catheters

Abstract Number: S4C-2
Abstract Type: Case Report/Case Series

Emily Dinges MD1 ; Zackary Schwamb DO2; Sheena Hembrador MD3; Laurent Bollag MD4

SMA type II is a rare progressive neuromuscular disease of the spinal anterior motor neurons and brainstem with very few published obstetric anesthesia cases.1,2,3 Symptoms include various degrees of skeletal muscle atrophy, muscle weakness, pulmonary insufficiency, autonomic dysfunction, and dysphagia, all of which can worsen during pregnancy. An increased sensitivity to anesthetic agents and delayed postpartum recovery has been reported.1

Case:

We describe a 26-year-old G1P0 (BMI 21.5 kg/m2) with confirmed SMA II and preeclampsia with severe features. She was wheelchair dependent with severe restrictive lung disease, neurogenic bladder, limited mouth opening (3 cm) and reduced thyro-mental distance. Due to worsening comorbidities, a CS was planned at 34 weeks. After assessment in our high-risk clinic, an interdisciplinary delivery plan was formulated. Due to her diminishing pulmonary function and complete spinal fusion with Harrington rods, a combined general and regional anesthesia technique was selected.

After carefully and lengthy positioning on the OR table using pillows and foam, an IV lidocaine (80 mg) bolus was given to attenuate her cough response and an RSI performed using propofol (120 mg) and remifentanil (100 mcg) without muscle relaxation. The tracheal was easily intubated with a McGrath video laryngoscope. Anesthesia was maintained using TIVA (propofol 80 mcg/kg/min, remifentanil 0.5 mcg/kg/min) with minimal phenylephrine (0.2 mcg/kg/min).

The neonate was delivered and intubated by pediatrics for poor APGAR scores. After delivery, an oxytocin infusion was started and good uterine tone was rapidly achieved. IV ketorolac and acetaminophen were administered. Prior to successfully extubating in the OR, ultrasound guided bilateral TAP catheters were placed. Each was dosed with 15 mL of 0.2% ropivacaine. She uneventfully recovered in the ICU for one day. Each TAP catheter was infused with 5 mL/hr of 0.2% ropivacaine. Pain management was excellent, and the catheters were removed late on POD 1.

At her 6 week follow up visit she reported no hoarseness, difficulties swallowing, or wound pain.

The baby was extubated within 4 hours of NICU admission and remained in the NICU for nutritional support. She was discharged 10 days later.

Discussion:

General,1 regional,2 and local3 techniques have all been used to provide cesarean anesthesia for the few published SMA II cases, but with varying degrees of success. Our patient received GA due to the concern for unpredictable neuraxial spread, if a block was successfully placed. Awake positioning of the patient prevented potential nerve, musculoskeletal, and skin injury. The use of TIVA and avoidance of muscle relaxants allowed for rapid extubation and recovery of pulmonary function, in addition to reducing the risks of atony and PONV. Good post-op analgesia, with minimal opioid requests, was achieved with continuous TAP blocks.

1-Bollag LRA 2011

2-Maruotti JCA 2012

3-Coffman IJOA 2016

SOAP 2018