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Anesthetic Management for Cesarean Delivery in Morbidly Obese Parturient With Enlarged Goiter
Abstract Number: RF3AC-352
Abstract Type: Case Report Case Series
A 33 year old G3P2002 woman was transferred at 37.5 weeks gestation for delivery planning. Her medical history was significant for super morbid obesity (BMI 63), untreated chronic hypertension and large multinodular goiter causing supine orthopnea. On physical exam, she had a palpable midline goiter without apparent tracheal deviation and a Mallampati 3 airway. Neck CT showed diffuse thyroid enlargement measuring 9.7 cm x 9.7 cm, multiple large nodules and airway narrowing with AP diameter of 5-6 mm at the narrowest point, 7 cm above the carina. Flexible nasal endoscopy showed no masses in upper aerodigestive tract and narrowing of trachea below vocal cords due to external compression.
The case was discussed at multidisciplinary meeting including OB, OB anesthesia, ENT, cardiothoracic surgery/ECMO team and ICU. Cesarean delivery (CD) was planned at 38 weeks. One day prior to surgery, aspiration of 55 mL cystic fluid was done for maximal decompression. Premedication with sodium citrate 30 mL, metoclopramide 10 mg, ondansetron 4 mg, dexamethasone 10 mg and glycopyrrolate 0.2 mg were given. Vascular access included PICC line, 18g and 14g peripheral IVs and left radial arterial line. An intentional intrathecal catheter (ITC) was placed. The airway was anesthetized with nebulized and topical lidocaine. Sedation was provided with a remifentanil infusion. A 6.5 cm endotracheal tube was placed via fiberoptic. The ECMO team was available for pre-emptive femoral vessel cannulation in the event that the airway could not be secured. The ENT team also present as backup. After successful intubation, 1.5 ml of 0.75% hyperbaric bupivacaine, 15 mcg fentanyl, and 0.1 mg morphine were titrated through the ITC to achieve a T4 anesthesia level. Remifentanil infusion was given throughout surgery for endotracheal tube tolerance. Pressure support ventilation was required once the neuraxial block was established due to increased work of breathing. She remained awake and aware with full recall of the delivery and was extubated in the OR once the neuraxial block receded and adequate respiratory parameters were achieved. She was monitored in ICU postoperatively.
This case was complicated by severe morbid obesity and an enlarged goiter causing severe airway obstruction. The use of neuraxial anesthesia avoided the risks of general anesthesia for a patient with BMI 63, allowed the mother to be awake for the delivery, and provided optimal postoperative analgesia with intrathecal morphine. Continuous spinal anesthesia allowed for careful titration of anesthetic level, minimizing the risk of high spinal in a patient with limited respiratory reserve. Electively securing the airway allowed for delivery of pressure support when the anesthetic level reached thoracic levels and allowed for easy conversion to general anesthesia if that became necessary.
Obstetrical and Gynecological Survey 56.10 (2001): 631-41
Indian Journal of Anaesthesia 60.4 (2016): 234