Quasi-Interesting OB Case

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33yo F G1 s/f C-Section at 36wks due to twins (di/di) with worsening IUGR and double breech presentation. Last meal at 1300 so OB puts her on for 2100. Not laboring and babies are fine on the strip.

-Uncomplicated pregnancy thus far aside from the aforementioned issues.
-PMHx significant for MS diagnosed 2 years ago which presented with hemiparesis. Diagnosis confirmed by MRI revealing thalamic plaque. She has since fully recovered. She follows up regularly with her neurologist, but is not currently on any treatment for MS.
-PSHx consists of spinal fusion for scoliosis as a teenager. She doesn't know if it's Harrington rods or pedical screws. She also had an IR guided LP 2 years ago as part of the MS work-up.
-She's 5'3" with a normal healthy BMI and good looking airway.
-Scar from the base of her neck all the way to her ass-crack.

Go. (as usual, students and residents first)
 
Don't over think it students and residents.

Edit: MS is always a good stem. This is a good one for residents to have concrete answers and god one-liner defenses for boards.
 
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anbuitachi said:
put a spinal in.. seems like a regular OB case
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tenor.gif
 
Wouldn’t touch that spine with a needle, especially without knowing what was actually done.

Since it’s been a couple years since she presented with hemi-paresis and she fully recovered there should be no issue with depolerizing NMBs.

So at risk of sounding like a big old copy cat: prop, sux, tube (TAP if you want to get fancy).
 
CA1 here writing from my phone so this won’t be conclusive....full neuro exam preop, counsel on likelihood of recrudescence. I need to look up drug issues still.
 
Beeftenderloin said:
Wouldn’t touch that spine with a needle, especially without knowing what was actually done.
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Are you more concerned by the hardware in her back or the MS? I've done spinals in both of those patient populations, though I don't think in the same patient.
 
MirrorTodd said:
CA1 here writing from my phone so this won’t be conclusive....full neuro exam preop, counsel on likelihood of recrudescence. I need to look up drug issues still.
Click to expand...

You must be from one of those fancy programs in the Northeast. None of my patients (or co-residents for that matter) would be able pronounce that, let alone know what it means.
 
Mman said:
Are you more concerned by the hardware in her back or the MS? I've done spinals in both of those patient populations, though I don't think in the same patient.
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CA1, just taking a stab at it, haven’t done OB yet. My limited exposure to spinal anesthesia has been in main OR. Had a patient with lumbar hardware that was otherwise a candidate for spinal and attending said just do GA ‘because of the hardware’.
 
Beeftenderloin said:
CA1, just taking a stab at it, haven’t done OB yet. My limited exposure to spinal anesthesia has been in main OR. Had a patient with lumbar hardware that was otherwise a candidate for spinal and attending said just do GA ‘because of the hardware’.
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spinals are usually pretty straightforward with hardware. Epidurals can be tough because their epidural space might be scarred down to nothing. But they still have a dura and you can just go midline and poke a hole in it the same as otherwise.
 
Typically avoid spinals in MS patient due to risk of relapse. With epidural the risk is much less. As epidural space is likely obliterated and there is no compelling reason to avoid GA would prop, sux, tube. If no MS would at least attempt spinal. You can always switch to GA if you can’t get it. Would not even attempt epidural catheter after the described neck to ass incision would try spinal catheter if needed for labor pain (assuming no MS)
 
WholeLottaGame7 said:
FWIW even the national MS society says any type of anesthesia is fine for delivery. Risk of relapse is high regardless of method post-partum, would warn the patient about that ahead of time so they don't blame the technique.
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Yea. Any type is fine in MS. Theres pretty much no good data on this supporting adverse events with spinal
 
San Marzano said:
Don’t you want to avoid hyperthermia with MS?
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you want to avoid hypothermia. Not sure I've ever seen a patient with a spinal get hyperthermic, even in a warm delivery room.
 
Mman said:
spinals are usually pretty straightforward with hardware. Epidurals can be tough because their epidural space might be scarred down to nothing. But they still have a dura and you can just go midline and poke a hole in it the same as otherwise.
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This. Why are people afraid is spinals with hardware? Surgeon marked midline for you even!!!
 
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I would try a spinal. If no CSF on the first stab then she goes to sleep because it’s 9PM and I need to get some sleep as well.
 
standard asa monitors, fluid, isobaric spinal plus minus a bit of fent
Roll to pacu and sign out
 
San Marzano said:
Don’t you want to avoid hyperthermia with MS?
Click to expand...

That post was just a joking post... but yes---> some MS patients are extremely sensitive to heat. I always ask about it.

All joking aside, I'd do a spinal and ask the patient about heat sensitivity. If difficult, p/s/t.
 
I just feel like...

MS flare post partum is a know risk.

MS post GA is also a risk so you could be blamed and given the entire stem would be easiest for everyone

MS post spinal is also a risk and you will definitely be blamed and you have to deal with neuraxial anesthesia at 9pm in a patient who could or could not be difficult due to anatomy, especially given the length of the incision

Im highly leaning towards a GA
 
I hate playing defensive medicine.
Sometimes you have to do it, sometimes you don’t.
 
In the end, do whatever you feel is the best outcome for the patient—> that’s the right choice.
 
sevoflurane said:
That post was just a joking post... but yes---> some MS patients are extremely sensitive to heat. I always ask about it.

All joking aside, I'd do a spinal and ask the patient about heat sensitivity. If difficult, p/s/t.
Click to expand...

I’d rather deal with an MS flare than listen to the NICU team bitch when I turn the temp of the room down
 
Mman said:
you ever see a patient with a spinal in OB get febrile during a c-section?
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Nope but I know the board answer (and have taken care of patients that have experienced this) is that patients who are hot are more likely to have an MS flare.

Not saying you have to get the Arctic Sun in the room, but I wouldn’t turn the thermostat up either.
 
SaltyDog said:
33yo F G1 s/f C-Section at 36wks due to twins (di/di) with worsening IUGR and double breech presentation. Last meal at 1300 so OB puts her on for 2100. Not laboring and babies are fine on the strip.

-Uncomplicated pregnancy thus far aside from the aforementioned issues.
-PMHx significant for MS diagnosed 2 years ago which presented with hemiparesis. Diagnosis confirmed by MRI revealing thalamic plaque. She has since fully recovered. She follows up regularly with her neurologist, but is not currently on any treatment for MS.
-PSHx consists of spinal fusion for scoliosis as a teenager. She doesn't know if it's Harrington rods or pedical screws. She also had an IR guided LP 2 years ago as part of the MS work-up.
-She's 5'3" with a normal healthy BMI and good looking airway.
-Scar from the base of her neck all the way to her ass-crack.

Go. (as usual, students and residents first)
Click to expand...

People seem to be continually confused on the prior back surgery and neuraxial anesthesia question

From a past post of mine:



No epidural at level of prior posterior back surgery, anywhere near a posterior back surgery would be my recommendation.

Without imaging, you really have little idea what level you are at. The scar on their back is not a reliable indicator of where you are working relative to the surgery as surgical approaches vary.

The issue is whether the ligamentum flavum is in tact. Otherwise, you will just plow right through to the dural sac. In any type of decompression surgery (such as a lami or a fusion) the flavum is removed, and so is the epidural space.

Also, There is scarring and alteration of anatomy resulting in increased risk of complications including bleeding. Think about "threading" a catheter through that scar tissue...a recipe for bleeding, dural tear, etc. A dozen plus case reports published of horrible complications with interlaminar (the approach you would be doing in OR/OB) epidural injections in the pain world in people who have had prior lumbar surgery at that level, and some at levels above/below.

A spinal you can always do after lami/microdisc...you are just trying to spear a big sac with a small needle anyway.

And dont worry about hardware infection if your technique is totally sterile. Risk is very minimal.
 
Shimmy8 said:
Nope but I know the board answer (and have taken care of patients that have experienced this) is that patients who are hot are more likely to have an MS flare.

Not saying you have to get the Arctic Sun in the room, but I wouldn’t turn the thermostat up either.
Click to expand...

nobody works to prevent hyperthermia in a c-section (even with a hot room), it prevents itself
 
Twiggidy said:
Given this is a forum that should have some basis of education involved, on the record I think every patient should have temperature monitored.

Off the record, LOL
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I joke about a lot of academic BS, but not about monitoring requirements for what might be a > 1 hour case. I'm willing to forgo temp monitoring for a 60 second case, not for major abdominal surgery. That's my real world private practice answer.
 
Mman said:
you don't monitor temps on your patients not under GA? We check them all.
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ASA standard 5.2:
Every patient receiving anesthesia shall have temperature monitored when clinically significant changes in body temperature are intended, anticipated or suspected.


I do many cases for which I don't intend, anticipate, or suspect clinically significant changes in temperature.
 
Mman said:
I joke about a lot of academic BS, but not about monitoring requirements for what might be a > 1 hour case. I'm willing to forgo temp monitoring for a 60 second case, not for major abdominal surgery. That's my real world private practice answer.
Click to expand...
Are you using skin probes to do this on awake patients or foleys with temp probes?
 
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