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| CASE REPORT |
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| Year : 2023 | Volume
: 2
| Issue : 1 | Page : 50-52 |
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Ultralow-dose spinal anesthesia in a short stature emergency cesarean section
Chanchal Nigam, Michell Gulabani, Asha Tyagi, Meghna Choudhary
Department of Anaesthesiology and Critical Care, University College of Medical Sciences, Guru Teg Bahadur Hospital, New Delhi, India
| Date of Submission | 17-Apr-2023 |
| Date of Acceptance | 30-Apr-2023 |
| Date of Web Publication | 25-May-2023 |
Correspondence Address:
Dr. Chanchal Nigam
Senior Resident, Department of Anaesthesiology and Critical Care, University College of Medical Sciences, GTB Hospital, Delhi - 110 095
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jica.jica_7_23
Anesthesia for parturients with short stature is envoked with unique challenges for the anesthesiologist. Difficulties with airway management, owing to the anatomical and physiological changes in pregnancy, risk of acid aspiration, and difficult regional anesthesia with the possible risk of failure/suboptimal effect, are well-documented. We describe the anesthetic management of a 20-year-old parturient of short stature with a height of 110.5 cm undergoing emergency cesarean section. A single-shot subarachnoid block with 4 mg intrathecal bupivacaine and adjuvant fentanyl 10 μg proved straightforward and reliable with no requirement of vasopressors.
Keywords: Bupivacaine, cesarean section, difficult airway, dwarfism, subarachnoid block
How to cite this article:
Nigam C, Gulabani M, Tyagi A, Choudhary M. Ultralow-dose spinal anesthesia in a short stature emergency cesarean section. J Ind Coll Anesth 2023;2:50-2 |
How to cite this URL:
Nigam C, Gulabani M, Tyagi A, Choudhary M. Ultralow-dose spinal anesthesia in a short stature emergency cesarean section. J Ind Coll Anesth [serial online] 2023 [cited 2023 Jun 8];2:50-2. Available from: https://www.jicajournal.in//text.asp?2023/2/1/50/377604 |
| Introduction | |  |
Anesthesia for parturients with short stature is envoked with unique challenges for the anesthesiologist. Cesarean sections are invariably the choice of termination of pregnancy in them due to cephalopelvic disproportion. The airway of a pregnant patient is known to be difficult due to the associated anatomical as well as physiological changes of pregnancy.[1] Regional anesthesia may also offer its own set of implications, including difficulty with intervertebral space identification, poor bony landmarks, or spinal deformity in cases of dwarfism.[2] There is a dearth in the literature regarding the anesthetic management of parturients with dwarfism. The choice of anesthetic technique and management for cesarean section depend on multiple factors, including the type of surgery such as emergency or elective procedure, physiological presentation of the patient, experience of the anesthesiologist, and availability of drugs/equipment.
The present case describes the anesthetic management of a 20-year-old parturient with dwarfism undergoing emergency cesarean section.
| Case Report | | |
A short-statured, 20-year-old second gravida, polyhydramnios in labor at term, with the breech presentation was taken for an emergency cesarean section. The uterine ultrasonography performed at 34 weeks revealed polyhydramnios and decreased foot length ratio (0.85) in the fetus suggestive of skeletal dysplasia. She had undergone a cesarean section 2 years ago successfully under regional anesthesia.
On physical examination, she was proportionately short in stature. Her height was 110.5 cm [Figure 1], corresponding to a 7-year-old girl, and her weight was 34 kg. She had a large head and prominent frontal bones. On airway examination, she had an adequate mouth opening and protruding upper central incisors with limited neck extension. Her modified Mallampati class was II. Examination of the cardiovascular and respiratory systems was unremarkable. Examination of the spine revealed lumbar lordosis and mild scoliosis. Preoperative investigations were within the normal limits.
An experienced team comprising an anesthesiologist, obstetrician, and neonatologist was in attendance. After shifting the patient to the operating room, all routine monitors were applied and continuously monitored. Oxygen supplementation was initiated through a simple facemask at 5 L/min, and left uterine displacement was ensured. Her baseline blood pressure was 123/63 mmHg, heart rate was 104 beats/min, and oxygen saturation was 99% on room air. An 18G intravenous access was established, and Ringer's lactate was initiated at 10 mL/kg as coloading.
With the patient in the right lateral position, the subarachnoid block was performed at the L4-5 intervertebral space through the midline approach with the 25G pencil-point Quincke needle. After confirming the free flow of cerebrospinal fluid, 4 mg of hyperbaric bupivacaine (0.5%) with 10 μg fentanyl (total volume 1 ml) was injected intrathecally. The patient was immediately placed in a supine position maintaining left uterine displacement. A bilateral T4 sensory level to pinprick was obtained after 1 min. The surgery commenced through a Pfannenstiel incision, and a 2.5 kg female infant was delivered with the APGAR scores of 7 and 9 at 1 and 5 min, respectively. A bolus dose of oxytocin 2 U was administered, followed by an infusion of 20 U oxytocin in 0.9% saline 500 mL over 5 h. The uterus was well contracted, and the remaining surgical procedure continued uneventfully. All hemodynamic parameters were well-preserved throughout the surgery without any requirement for vasopressors.
| Discussion | | |
Our patient was short-statured, had an anticipated difficult airway in view of limited neck extension, and protruding upper incisors with cephalopelvic disproportion necessitating cesarean section. Owing to the fact that an obstetric airway is considered difficult, pertaining to the anatomical and physiological changes of pregnancy resulting in an increased risk of aspiration and the emergency nature of surgery in this case, we planned regional anesthesia in the form of a subarachnoid block as an optimal choice for the patient.[1]
Regional anesthesia in this case of dwarfism was also technically difficult with a possible risk of unpredictable cephalad spread of the local anesthetic leading to a high/total spinal or even a failed spinal.[3]
On reviewing the literature, regional anesthesia in the form of a single-shot spinal, epidural, or combined spinal epidural has been preferred as the technique of choice in similar cases of dwarfism.[1],[4],[5]
These case reports are, however, of obstetric patients who had dwarfism associated with diagnosed genetic abnormalities such as achondroplasia or pituitary dwarfism, unlike the present case where the remarkable feature was an extremely short stature.[6]
Due to the unpredictability in the neuraxial spread, arbitrarily decreasing the intrathecal dose may be unreliable; however, in contrast, it would be prudent to reduce the dose of spinal anesthetic in a patient with short stature and a narrow spinal canal.[3] We administered 4 mg bupivacaine (dose decreased by 55%) due to her short stature, obtaining a bilateral block to T4 after 1 min with no requirement of vasopressors during the surgery.
A good predictor for a pain-free cesarean section is to ensure a loss of light-touch sensation up to T5, which we achieved in our case with the dose of bupivacaine chosen.[7]
Low-dose intrathecal bupivacaine combined with fentanyl has been reported in various studies to be successful in obstetric patients undergoing cesarean sections, with the dose ranging from 5 to 8 mg.[8],[9] Hence, since we used an ultralow dose of <5 mg, this case stands prominent among the existing ones.
There are lacunae in the literature regarding reporting of such cases, especially in the Indian context where the obstetric population is large and the incidence of cesarean sections is approximately 21.5% in both government and private sectors.[10] We could not locate any study in the literature, where the volume of intrathecal drug administered was limited to 1 mL.
The safety of both lives is paramount in obstetric patients, and hence, we aim to highlight the fact that an ultralow-dose single-shot subarachnoid block proved successful with no complications in this case with short stature and may be preferred over epidural anesthesia in emergency situations where time is of the essence.
| Conclusion | | |
A single-shot ultralow-dose subarachnoid block is safe, reliable, and effective in a case of dwarfism for emergency cesarean section. The importance of choosing the optimal dose has been emphasized in the present case.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Kacmar RM, Gaiser R. Chestnut's Obstetric Anesthesia Principles and Practice. 6 th ed., Ch. 2. China: Elsevier publication; 2020. p. 13-37.  |
| 2. | Li X, Duan H, Zuo M. Case report: Anesthesia management for emergency cesarean section in a patient with dwarfism. BMC Anesthesiol 2015;15:59. |
| 3. | Palomero MA, Vargas MC, Peláez EM, Rodríguez-Cerón A, Sánchez-Conde P, Muriel C. Spinal anaesthesia for emergency Caesarean section in an achondroplastic patient. Eur J Anaesthesiol 2007;24:981-2. |
| 4. | Dubiel L, Scott GA, Agaram R, McGrady E, Duncan A, Litchfield KN. Achondroplasia: Anaesthetic challenges for caesarean section. Int J Obstet Anesth 2014;23:274-8. |
| 5. | Teoh WH, Thomas E, Tan HM. Ultra-low dose combined spinal-epidural anesthesia with intrathecal bupivacaine 3.75 mg for cesarean delivery: A randomized controlled trial. Int J Obstet Anesth 2006;15:273-8. |
| 6. | Porter M, Mendonca C. Anaesthesia for Caesarean section in a patient with diastrophic dwarfism. Int J Obstet Anesth 2007;16:145-8. |
| 7. | Russell IF. Assessing the block for caesarean section. Int J Obstet Anesth 2001;10:83-5. |
| 8. | Ben-David B, Miller G, Gavriel R, Gurevitch A. Low-dose bupivacaine-fentanyl spinal anesthesia for cesarean delivery. Reg Anesth Pain Med 2000;25:235-9. |
| 9. | Choi DH, Ahn HJ, Kim MH. Bupivacaine-sparing effect of fentanyl in spinal anesthesia for cesarean delivery. Reg Anesth Pain Med 2000;25:240-5. |
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[Figure 1]
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