Spinal anaesthesia for emergency Caesarean section in an achondroplastic patient

Incidence and factors associated with failed spinal anaesthesia among patients undergoing surgery: a multi- center prospective observational study

BACKGROUND

Failed spinal anaesthesia causes prolonging of operation time, insufficient analgesia for surgery and needs repeating spinal anaesthesia which in turn causes local anaesthesia toxicity, high spinal and total spinal, and conversion to general anaesthesia. However, the problem remains unexplored in Amhara regional state comprehensive specialized hospitals.

OBJECTIVE

To determine incidence and factors associated with failed spinal anaesthesia among patients undergoing surgery in selected Amhara National Regional State comprehensive specialized hospitals, Northwest Ethiopia, 2023.

METHODS

Multi-center prospective observational study was conducted. Data was collected using questionnaire and checklist. All consecutive scheduled emergency and elective patients were included in the study. Data was transformed from Epi data to SPSS and logistic regression analysis was done. Both crude and adjusted odds ratio were used to assess the strength of association. Variables with a p-value of less than 0.05 were considered as statistically significant.

RESULTS

A total of 532 patients were included in this study with a response rate of 98%. Incidence of failed spinal anaesthesia was 22.4% (CI = 19-25.9). Emergency surgery (AOR = 7.01, CI = 4.5-12.7), dose of bupivacaine of ≤ 10 mg (AOR = 3.02, CI = 1.3-10.2), work experience of anaesthetist < 2 years (AOR = 3.1, CI = 1.7-5.72), bloody CSF (AOR = 8.5, CI = 2.53-18.5), hyperbaric local anaesthetic drug (AOR = 3.3, 95% CI = 3.2-8.2) and local anaesthetist without adjuvants (AOR = 5.25, CI = 2.62-14.2) were associated failed spinal anaesthesia.

CONCLUSION AND RECOMMENDATION

The incidence of failed spinal anaesthesia was high in Amhara Region comprehensive specialized hospitals. We suggest that anaesthesia providers should minimize failure by using adjuvants and appropriate dose of local anaesthetic. Additionally, simulation training should be given for anaesthesia trainees to improve their skills and to produce competent professionals.

Exacerbation of Spinal Stenosis Symptoms Following Neuraxial Anesthesia in an Achondroplastic Cesarean Section

We report the case of an achondroplastic female who presented with acute neurologic decline following epidural anesthesia for an elective cesarean section. Achondroplasia presents unique anatomical challenges to anesthesiologists in perioperative management, and cesarean sections are standard for achondroplastic pregnancies. High rates of spinal stenosis and lumbar radiculopathy in this patient population make administration of epidural analgesia technically challenging and may increase the risk of neurologic injury. Ultrasound is an effective means of administering epidural anesthesia for most patients; however, its utility is user-dependent and more challenging for those with obesity and abnormal spinal anatomy, both of which are common in achondroplasia. Cephalic and thoracic anatomical features in achondroplasia can also make general anesthesia challenging. Therefore, preoperative imaging may help guide preoperative planning based on patient anatomy and individual risk factors to reduce the risks of complications in this patient population. This report includes details from the patient's prenatal care, cesarean section, and 18 months of follow-up.

Real-time ultrasound-guided epidural anesthesia for cesarean section in a parturient with achondroplasia

Achondroplasia is a type of disproportionate dwarfism with short limbs and a normal-sized torso. This condition results in a potential spinal abnormality and a difficult airway may increase the anesthetic risk, not only in neuraxial anesthesia, but also in general anesthesia. We report a 25-year-old primigravida with achondroplasia who underwent cesarean section under epidural anesthesia with the assistance of real-time ultrasound guidance. A total dose of 17 mL 2% lidocaine with 7.5 μg sufentanil was administered via epidural catheter intermittently. The level of anesthesia reached T4. No other anesthetic was administered during the operation and the procedure was uneventful. The mother and her newborn were routinely discharged without any adverse events. During the follow-up at 10 months postoperatively, the patient did not have any discomfort. We suggest that titrated epidural anesthesia at the time of real-time ultrasound-guidance is a safe and effective epidural anesthesia for patients with achondroplasia.

Anesthetic management for Cesarean delivery in parturients with a diagnosis of dwarfism

PURPOSE

The literature on the anesthetic management of parturients with dwarfism is sparse and limited to isolated case reports. Pregnancy complications associated with dwarfism include an increased risk of respiratory compromise, an increased risk of Cesarean delivery, and an unpredictable degree of anesthesia with neuraxial techniques. Therefore, we conducted this retrospective review to evaluate the anesthetic management of parturients with a diagnosis of dwarfism.

METHODS

We used a query of billing data to identify short statured women who underwent a Cesarean delivery during May 1, 2008 to May 1, 2013. We then hand searched the electronic medical record for qualifying patients with heights < 148 cm and a diagnosis of dwarfism. The extracted data included patient demographics and obstetric and anesthetic information.

RESULTS

We identified 13 women with dwarfism who had 15 Cesarean deliveries in total. Twelve of the women had disproportionate dwarfism, and ten of the 15 Cesarean deliveries were due to cephalopelvic disproportion. Neuraxial anesthesia was attempted in 93% of deliveries. The dose chosen for initiation of neuraxial anesthesia was lower than the typical doses used in parturients of normal stature. Neuraxial anesthetic complications included difficult neuraxial placement (64%), high spinal (7%), inadequate surgical level (13%), and unrecognized intrathecal catheter (7%).

CONCLUSIONS

The data collected suggest that females with a diagnosis of dwarfism may have difficult neuraxial placement and potentially require lower dosages of local anesthetic for both spinal and epidural anesthesia to achieve adequate surgical blockade.

Failed rapid sequence induction in an achondroplastic dwarf

Achondroplasia, a common cause of short limbed type of dwarfism is due to quantitative decrease in rate of endochondral ossification. This abnormal bone growth leads to disproportionate body and head structure, thus placing them under high risk for anaesthetic management. There is paucity in literatures, regarding appropriate drug dosage selection in these patients. Use of drugs as per standard dosage recommendations based on body weight or body surface area, may not be adequate in these patients owing to discrepancies in overall body weight and lean body weight, especially during rapid sequence induction. Here, we report a case of failed rapid sequence induction due to abnormal response to administered drugs in an adult achondroplastic dwarf. Standard doses of thiopentone and rocuronium had to be repeated thrice to achieve adequate conditions for intubation.