2017 FSA Posters

P030: ANESTHESIA FOR CAESAREAN SECTION IN A MORBID OBESE PATIENT WITH DWARFISM.
Alfredo E Burgos Briceno, MD, Carol A Diachun, MD, MSEd; University of Florida - Jacksonville

Introduction: The current literature of the anesthetic management of Dwarf pregnant patients is limited to only case reports; there is no standard approach to pregnant patients with this condition. Even though neuroaxial anesthesia is the standard of care for most elective caesarean sections, a pregnant patient with morbid obesity and dwarfism represents a challenge for the anesthesia care provider.

Dwarf is defined as an adult height of 148cm or less. Multiple are the etiologies, including genetic, metabolic and constitutional predisposition to short stature. Both general and regional anesthesia present challenges for the pregnant dwarf patient: difficult intubation, decreased functional residual capacity (FRC), poor anatomical landmarks, narrow spinal and epidural spaces, prolapsed discs, deformed vertebras, excess skin and subcutaneous space are some of those findings.

Case Description: This was a 22 y.o female with a BMI 73.56 (Height: 1.44m, Weight: 153.9Kg). She had a history of family short stature, and presented with short limbs, wrist deformities and a history of ankle and foot clubbing from birth. 

On admission she was on her second gestation with a previous classical caesarean section, scheduled for repeat caesarean section at 37weeks gestation. Her past medical history was remarkable for morbid obesity, hypertension, acid reflux and tobacco abuse. On physical examination she had a short appearance, generalized obesity with short limbs, and Class IV airway.

After discussing with the patient the potential risk of neuroaxial versus general anesthesia, it was decided to proceed with lumbar epidural anesthesia. The patient was monitored per standard ASA guidelines, placed in sitting position. The patient’s landmarks were identified to best of ability due to BMI. In usual sterile manner epidural placement was attempted. On the first try a 17 Gauge, 6 inch, Tuohy needle was advanced using midline approach and LOR to saline technique in L2-3 interspace. Epidural space was located at 17cm (Depth estimated due to BMI and skin indenting with 6in Tuohy needle) from skin after 2 attempts. A test dose of Lidocaine with Epinephrine was injected one time with negative results however no block level was obtained. The second try was done with an 18 G 6 inch Tuohy needle at L3-L4 level, a similar catheter was placed but again the patient did not achieve block level. On the last try an 18 Gauge 6 inch Tuohy needle was advanced using midline approach in L3-4 interspace. A purposeful dural puncture for spinal catheter placement was done (after 3 attempts). Catheter placement was positive for cerebrospinal fluid aspiration. Only 1mL bupivacaine 0.75% in divided doses was required for T3 level bilaterally.  Case proceeded successfully and healthy baby was delivered.  Patient had no headache postoperatively.

Conclusion: In summary, we report a case of intentional spinal catheter placement after multiple fail attempts of epidural placement for a Caesarean section in a morbid obese dwarf patient.