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Management of a Parturient with a Spinal Cord Injury and Intrathecal Baclofen Pump
Abstract Number: T3D-7
Abstract Type: Case Report/Case Series
Introduction:The management of a parturient with a spinal cord injury (SCI) and intrathecal pump poses unique challenges to the obstetric anesthesiologist. Injuries above T6 predispose patients to autonomic hyperreflexia (AH), which can be life-threatening to both parturient and fetus(1). Additionally, the presence of intrathecal devices can make the placement of neuraxial anesthesia difficult and potentially ineffective.
Case:31 yo G2P1 presented at 36.4 weeks with advanced cervical dilation and PMH significant for an incomplete T3-5 SCI secondary to MVA eight years prior. Her SCI resulted in prolonged hospitalization requiring tracheostomy/PEG, multiple abdominal surgeries, neurogenic bladder, and spasticity s/p two intrathecal baclofen (ITB) pump procedures. Pregnancy had been complicated by recurrent UTI's, and she presented with urinary urgency with transient episodes of chest pain, dyspnea, and syncope. There was initial concern for AH, but this was determined unlikely given the length of time since her SCI and no history of prior episodes. Cardiac workup revealed normal TTE and no arrhythmias on telemetry. The pt's neurosurgeon was consulted and strongly advised against neuraxial procedures given the patient was already on her second ITB pump and there was significant scarring. The OB team attempted an external cephalic version (ECV) with fentanyl analgesia but was unsuccessful and preparation was made for cesarean delivery. Taking the neurosurgeon's recommendation into account, general anesthesia (GA) was planned. After appropriate aspiration prophylaxis, rapid sequence induction was performed, and ET tube placed without difficulty. Patient was monitored closely for signs of AH and remained hemodynamically stable throughout. The fetus' delivery was uneventful. Due to extensive adhesive disease, total duration of surgery exceeded 3.5 hours with an EBL of 1800 mL. The patient was extubated and recovered on the postpartum floor.
Discussion:Neuraxial procedures have been used safely in patients with IT devices(2) with varying success; however, epidural anesthesia was discouraged by pt's neurosurgeon. Epidural analgesia would have been particularly helpful for the ECV, which could have precipitated AH. A spinal anesthetic was considered for cesarean, as it posed less risk of injury to the ITB catheter; however, given the length of surgery, it would have been inappropriate. Though neuraxial anesthesia can prevent AH, GA can accomplish this as well(1). Strict hemodynamic monitoring is required to identify and treat autonomic instability with vasoactive medications. This case exemplifies the importance of multidisciplinary approach to a complex SCI patient.
1.Chestnut, David H. Chestnut's Obstetric Anesthesia: Principles and Practice. Elsevier/Saunders, 2014.
2.Esa, W. Ali Sakr, et al. "Epidural Analgesia in Labor for a Woman with an Intrathecal Baclofen Pump." International Journal of Obstetric Anesthesia, Vol 18(1), 2009, pp. 64-66.