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SLOWLY TITRATED COMBINED SPINAL-EPIDURAL IN A PATIENT WITH T6 SPINAL CORD INJURY AND TRACHEAL STENOSIS UNDERGOING CESAREAN DELIVERY
Abstract Number: RF4BD-277
Abstract Type: Case Report Case Series
Spinal Cord Injury (SCI) poses many challenges in obstetric anesthesiology. In these patients, both labor and cesarean delivery are potent stimuli of autonomic hyperreflexia (AH), which carries risk of significant morbidity and mortality. It is thus critical to achieve adequate neuroblockade, even with absence of pain. Monitoring of blockade in these patients can be unreliable due to limited sensory discrimination. We report on a patient with known AH from T6 SCI in the setting of tracheal stenosis, requiring careful neuraxial titration.
A 19 year-old G3P1 with a history of T6 SCI, presented at 39w1d for repeat cesarean delivery. Of note, she had full upper extremity motor & sensory function, with little to no motor or sensory function below T6. She had a known history of AH with bladder distension and other lower body stimuli. Additional history included current upper respiratory tract infection and tracheal stenosis, for which she did not comply with outpatient evaluation and imaging. Slowly titrated combined spinal-epidural (CSE) approach was selected in order to minimize risk of high neuroblockade or respiratory compromise that could necessitate endotracheal intubation. A low dose spinal, consisting of 1 ml of 0.75% hyperbaric bupivacaine, morphine 100mcg, and fentanyl 15mcg was used along with L3-4 epidural catheter. She was initially placed at 45°, gradually lowering the head of the bed to ~20-30° while monitoring respiratory status and neuroblockade level. An epidural catheter test dose (1.5% lidocaine with 1:200K epinephrine 3mL) was given, followed by two doses of 3 ml of 2% lidocaine with epinephrine at 30 minute intervals. Her poor sensory feedback prompted assessment of neuroblockade onset via temperature probe placed at the T8 level. In the first five minutes after the spinal dose, skin temperature rose by 2°C, where it then plateaued. Adequate surgical anesthesia was attained, and her intraoperative course was uneventful, without signs or symptoms of AH. EKG and SpO2 were monitored in the PACU for two hours and postpartum unit for 24 hours, without exhibiting any cardiopulmonary issues. She was discharged on post-op day 3.
In managing chronic SCI for cesarean delivery, adequate neuroblockade is needed to prevent AH, as neuraxial anesthesia causes inhibition of its afferent sensory component. Monitoring increased skin temperature as an indicator of sympathetic blockade allows for assessment of blockade level. With mid-thoracic SCI, pulmonary considerations, such as atelectasis and poor respiratory reserve, make avoidance of a general anesthetic preferred, particularly in our patient with tracheal stenosis and upper respiratory tract infection. Slow epidural titration after low dose spinal allows cautious blockade advancement to the level of patient detection.
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