Interesting OB Case

gaspassah · Jul 12, 2006

never fear!! underdog is here!! for those of you old enough to remember that cartoon,

i would reply to this but we already talked about this one, what's up underdogdude?

anymore issues in recovery?

d

skipaway · Jul 12, 2006

never fear!! underdog is here!! for those of you old enough to remember that cartoon,

Oh God! I'm so OLD....

good cartoon though.

underdog · Jul 12, 2006

Wassup Big "D"....Glad to say no issues intra-op or post-op, case went very smooth. Hope all is well with you in Ole Miss country.

J

AmiK25 · Jul 12, 2006

Well, I haven't done OB yet (September and October of this year) but I will give it a shot. I would do a spinal (as long as the patient does not have plates/rods/screws in the lumbar region...which is doesn't sound like she does). My concerns would be autonomic hyperreflexia (make sure she has an adequate block before proceeding....but I'm not really sure the best way to assess this given the fact that she has no sensory function below T6....do you just look at vital signs??) and hypoventilation if the spinal was too high becuase she may already have some respiratory insufficiency due to paralysis of abdominal accessory muscles. Obviously, avoid Sux if you have to do a general and I suppose I would choose Mivacron or try to do an awake fiberoptic intubation given the incidence of cannot intubate/cannot ventilate with pregnancy. Like I said, I haven't been to OB yet just wanted to venture a guess. I may be way off. How did you handle the case?

EmeraldNYL, BSN, RN · Jul 12, 2006

Wow what an interesting case. First of all, is it an incomplete or complete spinal cord injury? Does the patient have problems with spasticity d/t an incomplete lesion? For a complete lesion, you would expect a pain-free delivery, but I would probably want to do an epidural to prevent autonomic hyperreflexia. For GA, obviously a rapid sequence, but only use Succ if the injury has occured 6 mo. to 1 yr. ago (depending on the textbook you read). If the patient had problems with spasticity maybe baclofen during pregnancy??

chansonsrna · Jul 12, 2006

Like having the clinical questions...I agree w/spinal would have to b/c need to block to T4 for C-section. Also good to blunt r/o autonomic hyperreflexia. Would also consider regional as my primary technique unless I had to convert to GA. If converting to general would use pentathol and rocuronium due to fast onset as NDMRS wouldn't want succs because may cause severe hyperkalemia. Definately monitor for s/s hyperreflexia, hypoventillation. Haven't hit clinicals yet, but best shot.

underdog · Jul 12, 2006

Ami, Emerald, and Chanson....you all are right on the money with your concerns about autonomic hyperreflexia. First of all, a little more history on the case. She did have a complete SCI with sensory level at T-6. Her surgical history included a LEEP procedure being done since the SCI. She reported that she had a general anesthetic for that case. As the story goes, she developed full-blown autonomic hyperreflexia with severe HTN and bradycardia requiring an ICU admission and Nipride infusion. She was very well versed in the pathophys of autonomic hyperreflexia, as I have found many SCI patients are.

For this case, regional anesthesia was definitly my first choice. Her spine anatomy was not the greatest, but it was decent considering the circumstances (no plates/rods/screws). Before the case I was very deliberate about determining her sensory level. I chose to do an epidural as opposed to a SAB with reasoning being that I wanted to assure that I obtained a high enough level with my block to prevent autonomic hyperreflexia. Yea, it is relatively easy to get a t-4 level with SAB, but if by chance I did not get it up high enough with one-shot SAB, I was screwed. Therfore I chose epidural route and brought block up with 2% lidocaine to a T-4 level. In addition, I had some nipride in the room just in case.

As it turns out, case went very smooth with no s/s of autonomic hyperreflexia. Thanks for the replies.

J