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EPIDURAL ANESTHESIA FOR CESAREAN DELIVERY IN A PARTURIENT WITH LUMBOPERITONEAL SHUNT: A CASE REPORT
Abstract Number: T3D-4
Abstract Type: Case Report/Case Series
Parturients with pseudotumor cerebri, a disorder characterized by idiopathic elevation of intracranial pressure, may present with an indwelling lumboperitoneal shunt (LPS). (1) We present a case of successful epidural anesthesia for cesarean delivery in a parturient with a LPS.
A 26-year-old female, G3P2, at 37+1 weeks gestation with pseudotumor cerebri and LPS presented for repeat cesarean delivery in the setting of premature rupture of membranes. Neurology was consulted to discuss safety of placement of a neuraxial technique in the setting of LPS, and recommended placement of the epidural catheter below the site of LPS. A combined spinal-epidural technique was attempted using a 25G Pencan spinal needle in the L4-5 intervertebral space, below the site of scar from prior surgery, but no CSF flow was obtained. The epidural catheter was therefore placed and 3mL 1.5% lidocaine with 1:200K epinephrine was administered. After a negative test dose, 15mL chloroprocaine 3% was given in divided doses and a T3-T4 level was obtained. The patient reported an inability to move her upper extremities with subjective shortness of breath but remained conscious with stable vital signs throughout the cesarean delivery. The baby was delivered uneventfully with Apgars of 6 and 9. Thirty minutes later the parturient’s upper extremity motor function recovered and her shortness of breath resolved. Postoperatively, the parturient was transferred to the recovery room and had no further complications. She was discharged on postpartum day five.
Parturients with indwelling LPS catheter present a unique challenge to the obstetric anesthesiologist. While neuraxial anesthesia is not necessarily contraindicated in the parturient with LPS, the management may be more complex than expected. Previous authors have described failed epidural anesthesia following LPS placement due to scarring in the epidural space (2). Failed spinal anesthesia has also been described due to local anesthetic migrating to the peritoneal cavity through the shunt (3). Our parturient experienced a high spinal with standard dosing of local anesthetic for cesarean anesthesia, which may have been caused by the presence of a communication between the epidural and intrathecal spaces at the site of insertion of the LPS. While the “test dose” did not cause symptoms consistent with intrathecal injection, the increased volume of the chloroprocaine administered likely caused an increase in the epidural space pressure, increasing the gradient for flow from the epidural to the intrathecal space. Anesthesiologists taking care of parturients with LPS should be cautious when managing these parturients.
1 Tang et al. Curr Neurol Neurosci Rep, 2004
2 Bédard et al. Anesthesiology, 1999
3 Abouleish et al. Anesthesiology, 1985