|Year : 2022 | Volume
| Issue : 1 | Page : 76-78
Use of TIVA as an Adjuvant to SAB in a COVID-19-positive Parturient with Morbid Obesity Posted for Emergency Caesarean Section − A Case Report
Divya Gahlot, Bharti Wadhwa, Kirti Nath Saxena
Department of Anaesthesia, Maulana Azad Medical College, New Delhi, India
|Date of Submission||01-Apr-2021|
|Date of Decision||09-Dec-2021|
|Date of Acceptance||02-Jan-2022|
|Date of Web Publication||17-Jan-2022|
Dr. Divya Gahlot
Department of Anesthesia, MAMC, New Delhi
Source of Support: None, Conflict of Interest: None
Obstetric patients offer specific anesthesia concerns and associated coronavirus disease 2019 (COVID-19) infection makes the condition more challenging. We describe anesthetic management and difficulties encountered in a parturient with multiple comorbid conditions who came for an emergency caesarean section (CS). A 32-year-old morbid obese COVID-positive female G2P1L1 at 36 weeks gestation with previous LSCS, gestational hypertension, and diabetes presented for emergency CS in view of fetal distress. She had a respiratory rate of 24 to 28/minute maintaining a saturation of 94% to 95% on oxygen at 6 to 8 L/minute. Airway examination revealed mouth opening = 2.5 cm, Mallampati classification III, neck circumference 40 cm, temporomandibular distance 3.5 cm. Surgical duration was unusually prolonged and was successfully managed with total intravenous anesthesia (TIVA) as an adjuvant to subarachnoid block. We successfully managed an emergency CS of a morbidly obese parturient with COVID-19 infection using TIVA as a rescue anesthesia to central neuraxial block, avoiding conversion to general anesthesia, minimizing aerosolization and associated risk.
Keywords: Anesthesiology, COVID-19, morbid, obesity, obstetrics
|How to cite this article:|
Gahlot D, Wadhwa B, Saxena K. Use of TIVA as an Adjuvant to SAB in a COVID-19-positive Parturient with Morbid Obesity Posted for Emergency Caesarean Section − A Case Report. MAMC J Med Sci 2022;8:76-8
|How to cite this URL:|
Gahlot D, Wadhwa B, Saxena K. Use of TIVA as an Adjuvant to SAB in a COVID-19-positive Parturient with Morbid Obesity Posted for Emergency Caesarean Section − A Case Report. MAMC J Med Sci [serial online] 2022 [cited 2022 May 24];8:76-8. Available from: https://www.mamcjms.in/text.asp?2022/8/1/76/335902
| Introduction|| |
Obstetric anesthesia has always been challenging for the anesthesiologist and in a parturient with coronavirus disease 2019 (COVID-19) infection, these challenges become even greater. Apart from the usual anesthetic concerns due to the physiologic changes of pregnancy and concern for neonatal safety, the COVID-19 parturient has additional issues of associated respiratory and cardiovascular morbidity due to COVID infection, risk of transmission to healthcare workers, technical difficulties with wearing of personal protective equipment (PPE) and need for dedicated operating rooms with limited manpower. In such a situation, associated comorbidities can further increase the challenge to provide a safe anesthesia to patient.
We here describe successful anesthesia management and difficulties encountered in a parturient with multiple comorbid conditions: morbid obesity, gestational hypertension, gestational diabetes, and COVID-19-positive status who came for an emergency caesarean section (CS) in view of fetal distress.
| Case Report|| |
A 32-year-old COVID-positive female G2P1L1 at 36 weeks gestation with previous LSCS presented for emergency CS for fetal distress. She was a case of gestational hypertension controlled on tablet lobet 200 mg twice a day as well as gestational diabetes controlled on diet. She was obese with a body mass index 41.01 kg/m2(weight = 105 kg, height = 160 cm) with positive history of snoring. The parturient was diagnosed to have COVID-19 infection at 35 weeks of gestation when she developed fever, cough with loss of smell and taste. She received treatment: tablet azithromycin 500 mg once a day, tablet zinc and vitamin C, tablet ivermectin 12 mg once a day, and tablet paracetamol 650 mg as per the routine protocol at our hospital. She had a respiratory rate of 24 to 28/minute with SpO2 of 90% on room air and was being administered oxygen via face mask at 6 to 8 L/minute to maintain saturation of 94% to 95% when received for the CS.
The parturient was fasting since last 8 hours. The rest of the vital parameters as well as the investigations were normal. Both blood pressure and blood sugar were well controlled. Airway examination revealed mouth opening = 2.5 cm, Mallampati classification III, short neck, neck circumference 40 cm, and temporomandibular = 3.5 cm with adequate neck movements. Intervertebral spaces were narrow and difficult to palpate due to obesity.
In operating room, after taking a due risk consent from patient, routine American society of anesthesiologists (ASA) monitors were attached and baseline parameters recorded were blood pressure of 160/90 mmHg, pulse rate (PR) 122/minute, and SpO2 = 94% on oxygen via face mask at 6 L/minute. After coloading with 500 mL Ringer lactate, subarachnoid block (SAB) was attempted at L4 to L5 with a 23G long spinal needle (110 cm). On the third attempt, after free flow of cerebrospinal fluid (CSF), 1.8 mL of 0.5% bupivacaine (H) with 20 μg fentanyl was administered through the midline approach and patient in sitting position. A sensory level of T6 was achieved and surgery was proceeded with.
The duration of surgery was unusually prolonged and after 120 minutes from intrathecal injection, the sensory block regressed to T8 level and parturient started to complain of pain.
The regressing spinal anesthesia was supplemented by total intravenous anesthesia (TIVA) with titrated dose: propofol at 75 to 100 μg/kg/minute, fentanyl at 1 to 1.5 μg/kg/hour, and ketamine at 1 to 2 mg/kg/hour as per lean body weight. During intraoperative period, vitals remained stable and patient was comfortable and pain free. A healthy male baby 2.8 kg was delivered who later was tested negative for COVID-19. At the end of the surgery, transversus abdominis plane (TAP) block was given for postoperative pain relief.
The surgery lasted 160 minutes and the total blood loss was 800 mL. The postoperative stay was uneventful and patient was tested negative for COVID-19 on postoperative day 8 following which she was discharged on day 9 with her baby.
| Discussion|| |
Obstetric patients are special subpopulation owing to their specific anesthesia concerns and associated COVID-19 infection makes the condition even more challenging. Although the impact of COVID-19 infection in pregnant patients has been reported to be mild when compared with severe acute respiratory syndrome, Middle East respiratory syndrome, and influenza virus, an increase in rates of preterm labor and emergency CSs in view of fetal distress have been reported in literature. Moreover, emergency CS in a COVID-19 parturient poses the concerns of general anesthesia (GA), a greater risk of aerosolization with viral transmission to healthcare professionals with reduced skill sets when wearing PPEs.
We chose SAB as anesthesia technique of choice in our case but the sensory level regressed before the completion of surgery. TIVA in graded doses as adjuvant to SAB allowed for completion of the surgery. SAB was preferred over GA despite emergency fetal distress owing to concerns of anticipated difficult airway and risk of aspiration in the obese parturient and most significantly COVID-19 infection with respiratory compromise and associated hypoxia in our patient. Associated gestational hypertension and diabetes milletus (DM) further validated our choice of SAB.
In addition to above advantages, regional anesthesia is the accepted anesthesia of choice in COVID-19-positive patients due to maintenance of respiratory dynamics and reduced airway manipulation with reduced risk of viral transmission to healthcare workers benefiting both the parturient and the anesthesiologist. Although not reported till now, viral seeding of CSF and encephalitis remains a theoretical risk, thus strict aseptic precautions should be followed. As combined spinal epidural provides the additional advantage of prolongation of block when required, due to emergency situation and technical difficulty owing to obesity, epidural catheter insertion was not attempted.
Unfortunately, as a result of the morbid obesity, adhesions (consequence of previous LSCS) and reduced surgical dexterity due to wearing of bulky PPE, surgical time exceeded our expectations and patient started to complain of pain soon after the uterus was closed. The surgical team still required another 20 minutes to finish the procedure.
The GA with endotracheal intubation at this point of time seemed a formidable task with a high risk of complications. Proper positioning for intubation in this parturient with morbid obesity and application of intubation box as a barrier device to minimize aerosolization spread seemed an impossible task. We were apprehensive that attempting intubation in this situation may increase the risk of failed intubation leading to a potential cannot intubate, cannot ventilate situation. Further, attempts at relative strength index (RSI) presented the possibility of impaired oxygenation in a patient who was already oxygen dependent. RSI with endotracheal intubation seemed a challenging option that was fraught with complications and increased morbidity.
We decided to go for TIVA as a rescue anesthesia toward end of surgery with carefully graded doses of propofol, ketamine, and fentanyl titrated to pain relief. The sedation and pain relief were closely monitored and sedation was maintained at a Ramsay sedation score 2-3. The respiratory parameters were observed continuously and care was taken to avoid any respiratory depression or loss of consciousness. The difficult airway cart with videolaryngoscope and supraglottic airway device was kept standby at all times in the event of a need for intubation.
The TIVA offers several benefits in COVID-19 patients and is a safe and viable option for short surgical procedures and as adjuvant to regional anesthesia. It prevents airway manipulation, minimizes risk of aerosol generation in a spontaneous breathing patient, provides a stable hemodynamic, reduces postoperative nausea and vomiting, gives a better respiratory mechanics, and causes less immune depression than inhalational anesthesia giving an edge in this pandemic. However, drug selection and titration are of utmost importance. We understand that use of sedation in the parturient may be associated with risk of aspiration but due to associated comorbidities, COVID-19 infection and nature of surgery, titrated use of TIVA with close monitoring was considered to be the safest and most feasible option to supplement SAB in this case. Propofol and ketamine used together provided stable vitals and fentanyl supplemented additional analgesic properties. TAP block was used to supplement postoperative pain. Care regarding loss of airway reflexes, aspiration, and uteroplacental transfer should be kept in mind with use of TIVA in parturient. Dexmedetomidine, selective alpha 2 agonist owing to specific properties, appears to be a safer option to be used for TIVA in obese parturients. However, due to nonavailability of the drug in our setup at that time, we were unable to use it. We carefully titrated dose of fentanyl, ketamine, and propofol to maintain a Ramsay sedation score 2-3.
We successfully managed an obese, hypertensive, diabetic parturient with COVID-19 infection who came for an emergency CS and found use of TIVA as an adjuvant to central neuraxial block in a titrated manner a safe, effective, and practical alternative. COVID-19 operating rooms are often limited resource settings with reduced manpower to reduce the viral transmission in healthcare workers. Use of alternative anesthesia techniques that facilitate safety of healthcare professionals without compromising on patient comfort and safety are the need of the hour and can be a useful tool in our battle with COVID-19 infection.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ganesh V, Bhatia R, Trikha A. COVID-19: considerations for obstetric anesthesia and analgesia. J Obstet Anaesth Crit Care 2020;10:69-74. [Full text]
Liu Y, Chen H, Tang K, Guo Y. Withdrawn: clinical manifestations and outcome of SARS-CoV-2 infection during pregnancy. J Infect 2020.
Ponde VC, Diwan S, Gopal TV, Subramanian JB, Danish MA. Regional anesthesia in the coronavirus disease (COVID-19) pandemic: clinical guidelines by AORA, India. J Anaesthesiol Clin Pharmacol 2020;36:S109-15.
Lee AI, Hoffman MJ, Allen NN, Sullivan JT. Neuraxial labor analgesia in an obese parturient with influenza A H1N1. Int J Obstet Anesth 2010;19:223-6.
Chen R, Zhang Y, Huang L, Cheng BH, Xia ZY, Meng QT. Safety and efficacy of different anaesthetic regimens for parturients with COVID-19 undergoing caesrean delivery: a case series of 17 patients. Can J Anaesth 2020;67:655-63.
Chokshi T, Channabasappa S, Vergheese DC, Bajwa SJ, Gupta B, Mehdiratta L. Re-emergence of TIVA in COVID times. Indian J Anaesth 2020;64:S125-31.