P028: MODIFIED COMBINED SPINAL EPIDURAL ANESTHESIA FOR CESAREAN DELIVERY IN A PATIENT WITH GUILLAIN-BARRé SYNDROME
Alvaro Soto Rincon, MD; Reine Zbeidy, MD; UM/Jackson memorial Hospital
A 38 y/o gravida 2 para 0 at 39 weeks of gestation was transferred to our hospital with progressive ascending muscle weakness. Patient did not have a febrile episode preceding her current neurological deficit. She received her flu vaccine a month ago. Patient describes several weeks of tingling sensation in the bilateral feet and subsequent weakness in the lower extremities along with a burning sensation. She also developed difficulty swallowing and central facial paralysis.
No shortness of breath, bowel/bladder incontinence or autonomic symptoms were reported.
Physical exam showed areflexia and hyporeflexia throughout. Speech was fluent but slightly dysarthric. Facial sensation was intact, but unable to close both eyes, or activate a smile bilaterally. She had decreased muscle strength 3/5, mainly in the lower extremities, and a moderate bilateral upper extremities weakness 4/5. Light touch sensation was preserved, but sensation to pinprick was diminished below mid-thigh, and proprioception was completely abolished.
Preoperative course of the patient included IVIG therapy (2g/5 day) to prevent worsening of the symptoms. A multidisciplinary meeting before surgery included the neurology team, Obstetrics, pediatrics, and anesthesia. Decision for cesarian delivery was made for worsening maternal conditions including hoarseness and dysphonia. She was given antiemetic prophylaxis along with sodium citrate.
Standard ASA monitors were applied. Two intravenous access, and an A-line were placed. A Modified combined spinal epidural was performed in the lateral position at the level of L3-L4, using 1.2 ml of bupivacaine 0.75% with 15 micrograms of fentanyl and 0.1 mg of Duramorph in the intrathecal space. A T6 anesthetic level was slowly built using the epidural catheter to prevent profound hemodynamic changes. Supplemental oxygen was given through a nasal cannula and phenylephrine 20 mcg/min infusion was started to prevent hypotension. Patient remained stable throughout the operation. Estimated blood loss was 600 ml. Apgar scores were 9/9/9.
Post operatively the patient was transferred to ICU for close monitoring. She underwent aggressive physical therapy. She had persistent decreased sensation in bilateral lower extremities and bilateral paraesthesia in upper extremities, and few days later, she developed worsening of the respiratory symptoms and had to be intubated. She was extubated 20 days later.
Currently her motor function is progressively improving, and her speech is back to normal. She is using a walker and continuing her physical rehabilitation therapies.