Geeky medical story
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This is one of the reasons I'm so glad I'm retired.
A 36-year-old, gravida 1, nulliparous woman at 37 weeks’ gestation with a body mass index of 96 kg/m2 presented for an elective cesarean delivery due to fetal breech presentation. The patient’s medical history included obstructive sleep apnea (OSA), hypertension and type 2 diabetes. On admission, the patient was found to have preeclampsia with severe features and rapidly progressing thrombocytopenia, from 110,000 down to 80,000 platelets/mcL. She had no history of general anesthesia. Airway examination revealed a Mallampati class IV, large neck circumference, and limited neck extension and mouth opening.
This is every gaspasser's nightmare. You can't stick a needle in the back because of the low platelet count (and that's assuming you could even FIND the spine), and a really, really difficult airway for intubating.
"Now look here, you Baltic gas passer... " - Mik, 6/14/08
The saying, "Lite is just one damn thing after another," is a gross understatement. The damn things overlap.
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This is one of the reasons I'm so glad I'm retired.
A 36-year-old, gravida 1, nulliparous woman at 37 weeks’ gestation with a body mass index of 96 kg/m2 presented for an elective cesarean delivery due to fetal breech presentation. The patient’s medical history included obstructive sleep apnea (OSA), hypertension and type 2 diabetes. On admission, the patient was found to have preeclampsia with severe features and rapidly progressing thrombocytopenia, from 110,000 down to 80,000 platelets/mcL. She had no history of general anesthesia. Airway examination revealed a Mallampati class IV, large neck circumference, and limited neck extension and mouth opening.
This is every gaspasser's nightmare. You can't stick a needle in the back because of the low platelet count (and that's assuming you could even FIND the spine), and a really, really difficult airway for intubating.
@george-k said in Geeky medical story:
a body mass index of 96 kg/m2
WTF?
When I put my height into a BMI calculator, I'd need to weigh 350kg or 770lbs to get to 96.
I have nightmares merely thinking about how the impregnation must have looked like.
Also, what are these people thinking? At that body weight, she'll not be able to take care of a baby...
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@klaus said in Geeky medical story:
Do you know how the story continued, George?
This was one of those "what would you do?" cases, being a hypothetical.
"What are the anesthetic concerns and options to safely proceed with anesthesia for cesarean delivery?"
The article goes on to discuss options, dangers, etc.
The heaviest OB patient I ever put a needle into was about 177 kg. I held the record for a while, but then my partner got one that was about 15 kg. heavier.
The article concludes:
"Conclusion
- Super- and super super-morbidly obese patients are becoming increasingly common among women of reproductive age.
- Ultrasonography can assist successful placement of continuous lumbar spinal or epidural catheters.
- Dexmedetomidine and remifentanil are versatile medications that provide sedation and analgesia safely in the super-obese parturient.
- Since FONA may be more difficult due to the increased CTM depth, the use of ultrasound should be considered.
- There is increased risk for these patients to develop atelectasis and desaturation events. Extubation with CPAP/BiPAP should be considered."
If it were my case, and an elective c-section (as this was) I would have scheduled a consultation to meet with the
whalepatient and express my concerns and what my plan would be.Since she has a low platelet count, the danger of sticking a needle into the spine is significant, made even more dangerous by the likelihood of needing to do some "digging around" to find the subarachnoid space. I would opt for a general anesthetic.
However, those risks are not minor either, especially since you MUST intubate for a c-section under general. I would sedate the patient (as mentioned in #3 above) and intubate her awake.
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@klaus said in Geeky medical story:
Do you know how the story continued, George?
This was one of those "what would you do?" cases, being a hypothetical.
"What are the anesthetic concerns and options to safely proceed with anesthesia for cesarean delivery?"
The article goes on to discuss options, dangers, etc.
The heaviest OB patient I ever put a needle into was about 177 kg. I held the record for a while, but then my partner got one that was about 15 kg. heavier.
The article concludes:
"Conclusion
- Super- and super super-morbidly obese patients are becoming increasingly common among women of reproductive age.
- Ultrasonography can assist successful placement of continuous lumbar spinal or epidural catheters.
- Dexmedetomidine and remifentanil are versatile medications that provide sedation and analgesia safely in the super-obese parturient.
- Since FONA may be more difficult due to the increased CTM depth, the use of ultrasound should be considered.
- There is increased risk for these patients to develop atelectasis and desaturation events. Extubation with CPAP/BiPAP should be considered."
If it were my case, and an elective c-section (as this was) I would have scheduled a consultation to meet with the
whalepatient and express my concerns and what my plan would be.Since she has a low platelet count, the danger of sticking a needle into the spine is significant, made even more dangerous by the likelihood of needing to do some "digging around" to find the subarachnoid space. I would opt for a general anesthetic.
However, those risks are not minor either, especially since you MUST intubate for a c-section under general. I would sedate the patient (as mentioned in #3 above) and intubate her awake.
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A quick search has a case report of a spinal anesthetic in a patient with a BMI of 61.3.
https://pubmed.ncbi.nlm.nih.gov/32756154/
There are more.
My patient's BMI was 66.4, and I got the epidural in with one pass. Good thing the patient couldn't see my shocked face when I got it in, and the nurses did all they could to avoid "high-fiving" me.
