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Simultaneous labor epidural and interscalene nerve blockade for a parturient undergoing an induction of labor in the setting of severe pain from a right humerus fracture
Abstract Number: T1D-4
Abstract Type: Case Report/Case Series
Introduction: Humerus fractures during pregnancy and labor present unique challenges for the anesthesiologist, obstetrician, and orthopedist. We present our multidisciplinary approach to the management of a parturient at term who presented with severe pain from a right humerus fracture.
Case: A 34-year-old G2P1 at 40 and 3/7 weeks gestation presented with severe, unrelenting pain from a right humerus fracture sustained during a fall. The orthopedic surgery service was consulted and recommended further imaging to consider possible operative intervention. The patient desired to avoid opioids, further imaging and surgery while pregnant. A collective decision was made to proceed with an induction of labor in the setting of a right humerus fracture, with a probable postpartum repair.
To provide optimal pain control for the patient's fracture while avoiding opioids, an interscalene nerve block was performed using 7.5mL of 0.5% ropivacaine with a catheter placed to provide ongoing analgesia. The block provided complete analgesia and the patient was able to progress through labor without requiring any opioids. A labor epidural analgesia with bupivacaine 0.125% with fentanyl 2mcg/mL was infused at 6 mL/hour with PCEA bolus 6 mL and lockout of 15 minutes. Seven hours after the initial nerve block, the shoulder pain returned; unfortunately, the nerve catheter was nonfunctional and had to be replaced to good effect. The patient had an uneventful labor course and delivered a healthy infant. Postpartum, the patient underwent further imaging and was treated conservatively.
Discussion: Humerus fractures during pregnancy and labor are rare and pose unique challenges for the multidisciplinary team. Anesthetic challenges include avoiding fetal radiation and unnecessary surgery during pregnancy, minimizing opioid exposure, and providing optimal analgesia for the fracture and the labor; these ongoing analgesia needs are optimally provided with catheter-based techniques. An additional unique consideration is the avoidance of cumulative local anesthetic toxicity.
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