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

Neuraxial Anesthesia for Cesarean Section in ALS Patient

Abstract Number: S4C-8
Abstract Type: Case Report/Case Series

Marisa Pappas M.D.1 ; Melissa Russo M.D.2

Introduction: The incidence of ALS in pregnancy is low. This case presents the challenges encountered in a parturient with severe progressive neurodegenerative disease requiring cesarean delivery.

Case presentation: A 25 yr old G1P0 female with history significant for atypical motor neuron disease with ALS-like picture was referred for OB anesthesia consultation at 23 weeks for delivery planning.

The patient was diagnosed with neuromuscular disease 8 years prior. At the time of consultation, she was cachectic (BMI 12.8), endorsed progressive bilateral upper extremity weakness, lower extremity weakness requiring intermittent ambulation assistance, and dysarthria. She denied difficulty swallowing or any respiratory complaints. The patient was counseled on anesthetic options for delivery and seen in Pulmonology Clinic at 29 weeks. At that time her respiratory function was dependent on diaphragmatic excursion (with little accessory muscle use) and active expiration. Vital capacity was measured at 500cc. At 31 weeks, she presented to the OB ED with complaints of dehydration, nausea, decreased appetite, and shortness of breath. She was tachypneic with increased work of breathing but maintained oxygen saturations on room air. The patient was admitted to ICU where she received IVF and betamethasone series. Multiple multidisciplinary discussions were held and the decision was made to proceed with cesarean delivery at 32 2/7 weeks. Multidisciplinary concerns included patient positioning, anesthetic approach, possible ventilator requirements (both intraop and postop), risk of aspiration and postoperative analgesia. Anesthetic plan included neuraxial anesthesia, maintaining the block below T6 (to not decrease ERV) with IV supplementation as needed.

The patient was placed on the OR table with 45 degree elevation and modified lateral decubitus position. This was tolerated by patient and acceptable for performance of the surgical procedure. Sequential CSE was then performed with 7.5mg hyperbaric Bupivacaine and 10mcg Fentanyl. Chloroprocaine was titrated in slowly to obtain T6 level. An antisialagogue was administered to reduce secretions and NIV was available for support as needed. The patient maintained spontaneous respirations throughout, with oxygen saturations >96%. Postpartum, her respiratory status continued to be stable, maintaining oxygen saturations in high 90s on room air.

Discussion: Neuraxial anesthesia has long been the preferred method in obstetric anesthesia, offering patient comfort while avoiding the many complications associated with general anesthesia in parturients. As this case presentations illustrates, this method offers unique benefits to those patients with neuromuscular disease as well; with a multidisciplinary approach and advanced planning, a sequential CSE provided an adequate surgical anesthetic while preserving patients' baseline respiratory function both intraoperatively and postoperatively.

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