Ravindra V. Prasad,
MD Chapel
Hill, North Carolina
After preparing for and
discussing this case, the PBLD learner will be able to:
1.
Summarize the
anesthetic implications of Klippel-Feil Syndrome
2.
Manage neuraxial
anesthesia for anticoagulated patients
3.
Use the ASA
difficult airway algorithm
MS is a 33 year old, 5’3” 75kg woman with
Klippel-Feil Syndrome, gravida 2, para 1 at 32 weeks gestation. She has a
history of DVT, with PE after her caesarean-section two years ago and takes
Lovenox for DVT prophylaxis. Her medical history is otherwise unremarkable. She
presents to the labor and delivery suite for preoperative evaluation for
scheduled c-section at 38 weeks gestation.
What is Klippel-Feil Syndrome? Are there any
anesthetic implications?
How does Lovenox work? Are there any anesthetic
implications?
Do you need additional information (history,
physical, labs, diagnostic studies)?
What is your preferred anesthetic technique for
this patient?
At 37 weeks gestation, MS presents to the labor
and delivery suite in labor. Fetal heart rate tracing shows late decelerations
and decreased beat-to-beat variability. The obstetrician requests anesthesia
for urgent caesarean section. Airway exam reveals a Mallampati Class II
oropharyngeal view, slightly decreased neck range of motion, and thyromental
distance of 3 finger breadths.
Do you
need additional information?
What
anesthetic technique will you choose?
What, if
any, additional equipment do you require be available before proceeding?
Fetal
status has deteriorated; the obstetricians are preparing for emergency
c-section. You elect to proceed with a general anesthetic. The patient is
positioned with left uterine displacement and preoxygenated. After rapid
sequence induction with sodium thiopental and succinylcholine, with cricoid
pressure applied, direct laryngoscopy with a Macintosh 3 blade reveals only a
Grade IV view. There is no improvement in visualization despite repositioning
the patient and changing blades. A blind attempt is unsuccessful (esophageal).
You try to mask ventilate, but are having difficulty as the patient starts to
desaturate.
What do you do next?
Should you try to
intubate?
How can you improve your
mask airway?
You
call for help while attempting to mask ventilate. You are still unable to
ventilate after placing oro- and naso- pharyngeal airways. Your colleague
attempts laryngoscopy with a Miller blade but cannot identify the vocal cords or
epiglottis. The patient continues to desaturate.
What do you do next?
Should you allow the
obstetricians to begin surgery?
You tell the
obstetricians to proceed with surgery while you continue to manage the airway.
You and your colleague are unable to place either a size 3 or 4 LMA. You place
a Combitube and appear to have only minimal chest rise. However, the patient
continues to desaturate and is now hypotensive and having frequent multifocal
ventricular beats.
What do you do next?
Burns AM. Dorje P.
Lawes EG. Nielsen MS. Anaesthetic management of caesarean section for a mother
with pre-eclampsia, the Klippel-Feil syndrome and congenital hydrocephalus. British Journal of Anaesthesia.
61(3):350-4, 1988 Sep.
Dresner MR. Maclean AR.
Anaesthesia for caesarean section in a patient with Klippel-Feil syndrome. The
use of a microspinal catheter. Anaesthesia.
50(9):807-9, 1995 Sep.
Pizzutillo, PD. Woods
M. Nicholson, L. MacEwen GD. Risk Factors in Klippel-Feil Syndrome. Spine. 19(18): 2110-2116.
American Society of
Anesthesiologists Task Force on Management of the Difficult Airway. Practice
Guidelines for Management of the Difficult Airway. Anesthesiology, 78:597-602,
1993
http://www.asahq.org/Practice/Diff_Airway/difficult.html
Benumof JL. Management
of the difficult adult airway. Anesthesiology.
75: 1087-1110, 1991.
Anonymous. Neuraxial
Anesthesia and Anticoagulation, Consensus Statements. American Society of
Regional Anesthesia Consensus Conference, Chicago, Illinois, May 2-3, 1998. http://www.asra.com/consensus/index.shtml
Horlocker TT. Wedel DJ.
Neuraxial block and low-molecular-weight heparin: balancing perioperative
analgesia and thromboprophylaxis. Regional
Anesthesia & Pain Medicine. 23(6 Suppl 2):164-77, 1998 Nov-Dec.