Geeky medical story

[George K]

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.

[Mik]

We have never regretted bailing a bit early.

[Klaus]

@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...

[Klaus]

Do you know how the story continued, George?

[George K]

@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

1. Super- and super super-morbidly obese patients are becoming increasingly common among women of reproductive age.
2. Ultrasonography can assist successful placement of continuous lumbar spinal or epidural catheters.
3. Dexmedetomidine and remifentanil are versatile medications that provide sedation and analgesia safely in the super-obese parturient.
4. Since FONA may be more difficult due to the increased CTM depth, the use of ultrasound should be considered.
5. 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 whale patient 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.

[Klaus]

@george-k said in Geeky medical story:

This was one of those "what would you do?" cases, being a hypothetical.

OK, that's good to know.

People who are unable to take at least a minimum amount of care for themselves should not have kids.

[George K]

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.