Abstract
Purpose: Spinal cord injured patients present multiple unique challenges to the anesthesiologist. These include choice of muscle relaxant and management of autonomic hyperreflexia. We report the anesthetic management for Cesarean delivery in a patient who was paraplegic due to spinal canal metastases. Preeclampsia and fever complicated this case.
Clinical features: The patient presented at 29 wk gestation with progressive paraplegia at the T10 level due to metastatic osteosarcoma. She had a decompressive laminectomy without improvement in her paralysis. She subsequently developed preeclampsia at 31 wk gestation, and underwent Cesarean delivery for breech presentation under general anesthesia. Anatomical concerns left us unsure of the efficacy or safety of neuraxial anesthesia.
Conclusions: Preeclampsia and autonomic hyperreflexia are generally indications for regional anesthesia for Cesarean section. Tumour in her spinal canal and laboratory abnormalities including thrombocytopenia and a potential urosepsis dissuaded us from this option. Additionally, rapid sequence induction and intubation were not preferred due to paraplegia, leading us to secure the airway fibreoptically.
Résumé
Objectif: Les lésions de la moelle épinière représentent de nombreux défis anesthésiques particuliers comme le choix du myorelaxant ou le traitement de l’hyperréflexie autonome. Nous décrivons la conduite anesthésique adoptée pendant la césarienne d’une patiente paraplégique, à cause de métastases au canal rachidien, qui présentait aussi une préédampsie et de la fièvre.
Éléments diniques: L’examen de la patiente révélait, à 29 sem de grossesse, une paraplégie progressive à T10 causée par un ostéosarcome métastatique. Une laminectomie décompressive a été pratiquée sans changer la paralysie. À 31 sem, une prééclampsie s’est développée et, étant donné une présentation par siège, une césarienne sous anesthésie générale a eu lieu. Les problèmes anatomiques nous ont fait douter de l’efficacité ou de la sécurité de l’anesthésie régionale.
Conclusion: La prééclampsie et l’hyperréflexie autonome sont généralement des indications d’anesthésie régionale pour une césarienne. La tumeur du canal rachidien et les anomalies rapportées par le laboratoire, y compris une thrombocytopénie et une uropathie, nous ont dissuadés de l’utiliser. De plus, la paraplégie nous a amenés à privilégier la fibroscopie, plutôt que la séquence rapide pour l’induction et l’intubation, afin de protéger les voies aériennes.
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Jones, B.P., Milliken, B.C. & Penning, D.H. Anesthesia for cesarean section in a patient with paraplegia resulting from tumour metastases to spinal cord. Can J Anaesth 47, 1122–1128 (2000). https://doi.org/10.1007/BF03027967
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DOI: https://doi.org/10.1007/BF03027967