Anaesthesia for caesarean section in a patient with Klippel-Feil syndrome. The use of a microspinal catheter

Continuous Spinal Anaesthesia for Intertrochanteric Femur Fracture in a Patient with Skeletal Dysplasia

The practice of continuous spinal anaesthesia is not common. Though underutilised, it offers significant advantage when compared to the single-shot technique nonetheless. Time and again, it has proven its worth in patients with advanced cardiac illness, spinal deformities, and obesity. We here successfully employed this neuraxial anaesthetic technique in a sixty-two-year-old male patient with skeletal dysplasia, who presented for surgical fixation of intertrochanteric fracture of the femur. With short stature, anticipated difficult airway, and poor pulmonary status complicating the anaesthetic plan, we opted for continuous spinal anaesthesia. The procedure was carried out uneventfully with 8 mg of hyperbaric bupivacaine used in titration to anaesthetic needs. Patients with skeletal dysplasia present with wide array of clinical conditions that pose a formidable challenge to anaesthesiologists. Continuous spinal anaesthesia can be safely practiced in such patients as it provides a titratable form of neuraxial blockade with reduced dose of local anaesthesia. This, in turn, ensures a predictable block and, thus, hemodynamic stability.

Epidural anesthesia for repeat cesarean delivery in a parturient with Klippel-Feil syndrome

A patient with Klippel-Feil syndrome, morbid obesity, and scoliosis required cesarean delivery. Her previous cesarean deliveries were performed under general anesthesia. She desired a regional technique. Following aspiration prophylaxis and placement of standard monitors, ultrasound was used to identify midline and L_2-3 interspace. Unintentional dural puncture occurred at 10 cm, with an inability to advance the catheter. On second attempt, an epidural catheter was placed easily. After negative test dose, 18 ml of 2% lidocaine with epinephrine was administered to the patient. A T4 level was achieved. The patient tolerated surgery well. Complete block resolution occurred at 4 hours with no neurologic sequelae.

Dexmedetomidine for an awake fiber-optic intubation of a parturient with Klippel-Feil syndrome, Type I Arnold Chiari malformation and status post released tethered spinal cord presenting for repeat cesarean section

Patients with Klippel-Feil Syndrome (KFS) have congenital fusion of their cervical vertebrae due to a failure in the normal segmentation of the cervical vertebrae during the early weeks of gestation and also have myriad of other associated anomalies. Because of limited neck mobility, airway management in these patients can be a challenge for the anesthesiologist. We describe a unique case in which a dexmedetomidine infusion was used as sedation for an awake fiber-optic intubation in a parturient with Klippel-Feil Syndrome, who presented for elective cesarean delivery. A 36-year-old female, G2P1A0 with KFS (fusion of cervical vertebrae) who had prior cesarean section for breech presentation with difficult airway management was scheduled for repeat cesarean delivery. After obtaining an informed consent, patient was taken in the operating room and non-invasive monitors were applied. Dexmedetomidine infusion was started and after adequate sedation, an awake fiber-optic intubation was performed. General anesthetic was administered after intubation and dexmedetomidine infusion was continued on maintenance dose until extubation. Klippel-Feil Syndrome (KFS) is a rare congenital disorder for which the true incidence is unknown, which makes it even rare to see a parturient with this disease. Patients with KFS usually have other congenital abnormalities as well, sometimes including the whole thoraco-lumbar spine (Type III) precluding the use of neuraxial anesthesia for these patients. Obstetric patients with KFS can present unique challenges in administering anesthesia and analgesia, primarily as it relates to the airway and dexmedetomidine infusion has shown promising result to manage the airway through awake fiberoptic intubation without any adverse effects on mother and fetus.

[Continuous spinal anesthesia in obstetrics]

Despite the theoretical advantages of continuous anesthesia in obstetric patients (good-quality blockade at low doses, good hemodynamic stability, rapid onset of effect, and no risk of toxicity), little has been published on this technique and its use in pregnancy. Moreover, few descriptive studies or comparative trials have evaluated the efficacy and safety of continuous spinal anesthesia, probably because of concerns about potential adverse effects-principally neurologic complications and postdural puncture headache. We review the literature on the use of continuous spinal anesthesia in obstetric patients, analyzing the advantages and disadvantages, indications, and adverse effects of this technique.

Observational study of continuous spinal anesthesia with the catheter-over-needle technique for cesarean delivery

BACKGROUND

Few studies have assessed the efficacy and safety of continuous spinal anesthesia in obstetrics, although placement of a catheter in the intrathecal space theoretically offers advantages in these patients.

METHODS

Ninety-two women scheduled for elective cesarean delivery using continuous spinal anesthesia with the catheter-over-needle technique (22- or 24-gauge Spinocath) were included in the study. The doses of local anesthetic used, hemodynamic variables, use of ephedrine and other drugs, and incidence of complications such as technical failure and postdural puncture headache (PDPH) were recorded.

RESULTS

The mean (+/-SD) dose of hyperbaric bupivacaine used was 8.2+/-1.8 mg. The incidence of hypotension was 30% and the mean total dose of ephedrine was 4+/-7 mg. The continuous spinal anesthetic technique failed in 18 women (20%). The overall incidence of post-dural-puncture headache was 29%; 18% of patients with post-dural-puncture headache required a blood patch.

CONCLUSIONS

Compared to previous reports, the incidence of block failure and PDPH in this study was unacceptably high and therefore the risks of the technique appear to outweigh the advantages of continuous spinal anesthesia in obstetric practice.

Anaesthesia for caesarean section in women with complex cardiac disease: 34 cases using the Braun Spinocath spinal catheter

BACKGROUND

Cardiac disease in pregnancy is now the leading medical cause of maternal mortality in the UK. Whilst anaesthesia has not been the precipitant of this morbidity, its safety cannot be taken for granted. Spinal catheter anaesthesia, a relatively uncommon choice in obstetric practice, offers the potential of maintaining haemodynamic stability through accurate and gradual titration of neuraxial blockade.

METHODS

Thirty-four women with cardiac disease requiring caesarean section were selected for spinal catheter anaesthesia. All received invasive arterial pressure measurement but in only two were central venous catheters sited. After inserting a 24-gauge Braun Spinocath, spinal anaesthesia was induced using diamorphine 300 microg and 0.5% hyperbaric bupivacaine in 0.25-mL increments. Technical problems, block quality and haemodynamic stability were recorded.

RESULTS

Successful anaesthesia was achieved in 33 women. Spinal catheterisation proved impossible in one case, but the catheter was successfully used to provide epidural anaesthesia. There were no conversions to general anaesthesia. Eight women (24%) received supplementation with intravenous alfentanil, but all reported high satisfaction. Mild, transient hypotension occurred in six women (18%), and there was one case of vasovagal syncope induced by rapid exteriorisation of the uterus. Three patients (8.8%) experienced post dural puncture headache requiring a blood patch; two had received repeat dural puncture during catheter insertion.

CONCLUSIONS

Incremental spinal catheter anaesthesia offers effective anaesthesia with excellent haemodynamic control. Post dural puncture headache is of concern, and whilst it may be addressed by product modification, it currently limits widespread use of the Braun Spinocath in obstetric practice.

Spinal anesthesia in a patient with severe thoracolumbar kyphoscoliosis

Patients with spine abnormalities, present unique challenges to the health care provider responsible for administrating sedation and anesthesia during surgical and technical procedures. Spinal deformities may cause difficulties with both tracheal intubation and regional anesthesia. This report describes the anesthetic management for two urological operations that were performed in a patient with extremely severe thoracolumbar kyphoscoliosis. After examining the risk factors, spinal block by injecting single dose local anesthetic solution to the intratechal space was chosen to provide anesthesia. It has been suggested that hyperbaric solution, which is of high density compared with cerebrospinal fluid, can safely produce blocks for many operations under spinal anesthesia. In the first procedure, intrathecal injection of 6 mg hyperbaric bupivacaine, a local anesthetic solution (1.2 ml total volume), resulted in inadequate motor and sensory blockade, but the successful motor and sensory blockade at the level of Th10 was achieved in a second attempt with 6.25 mg hypobaric bupivacaine (2 ml). Because of this unexpected effect of local anesthetic solution, in the second operation, the technique was changed to intrathecal injection of 12.5 mg hypobaric bupivacaine (4 ml), and the motor and sensory blockade at Th10 was achieved again. The patient reported satisfactory anesthesia each time, and developed no complications. In conclusion, spinal anesthesia can be successful even in cases of severe thoracolumbar kyphoscoliosis.

Anaesthesia for caesarean section in a patient with diastrophic dwarfism

Diastrophic dwarfism is a rare disease in which pregnancy is uncommon. In this report we present a woman with diastrophic dwarfism who underwent caesarean section under epidural anaesthesia. Her care was successfully managed with multidisciplinary team planning. The total dose of local anaesthetic needed for epidural block was greater than the doses reported for achondroplastic dwarfism.

Incremental spinal anaesthesia for elective Caesarean section in a patient with Eisenmenger's syndrome

We describe a new approach to anaesthesia for elective Caesarean section in a woman with Eisenmenger's syndrome. Incremental regional anaesthesia was performed using a microspinal catheter and haemodynamic monitoring included transthoracic bioimpedance cardiography. This approach allowed the disadvantages of general anaesthesia and invasive cardiac output monitoring to be avoided.

Thoracic epidural anesthesia for bilateral reduction mammoplasty in a patient with Klippel-Feil syndrome

General anesthesia is best avoided in cases of Klippel-Feil syndrome where tracheal intubation is potentially difficult. The syndrome features severe abnormalities of the neck and upper thoracic spine, which may also lead to difficulties with neuraxial blockade. We describe the use of epidural anesthesia for bilateral reduction mammoplasty in a patient with this condition.