Determination of Puncture Point for Spinal Needle with Ultrasound in a Morbidly Obese Patient
Obesity, defined as a body mass index (BMI) ≥30 kg/m2 , is an important clinical condition that affects many organ systems. In addition to the systematic effects, obesity can lead to complexity in the application of clinical anesthesia, such as regional anesthesia approaches. The use of ultrasound (US) may be necessary to ensure the success and reliability of neuraxial blocks, especially in patients with anatomical landmarks that are difficult to determine. Presently described is a case with a morbidly obese patient case for whom we had to determine the puncture point for a spinal needle using US due to pulmonary issues. In the preoperative evaluation of this 69-year old, 180 kg, 150 cm tall, female patient with a BMI of 75 kg/m2 who had a fracture of the left femoral diaphysis, it was observed that she presented with wheezy breathing and a cough. The physical examination found that end expiration was prolonged and wheezing was auscultated at the end of expiration. Spinal anesthesia was administered to the patient with US guidance as a result of the pulmonary issues. She was admitted to the intensive care unit with no observed problem and was discharged to the orthopedic clinic the following day.
1.World Health Organization. BMI classification. Available at: http://apps.who.int/bmi/index.jsp?introPage=intro_3.html. Accessed Jul 11, 2016.
2. Ogunnaike BO, Whitten CW. Evaluation of the Obese Patient. In: Longnecker DE, Brown DL, Newman MF, Zapol WM. 2nd ed. New York: The McGraw-Hill; 2012. p. 301–14.
3. Duarte RL, Magalhães-da-Silveira FJ. Factors predictive of obstructive sleep apnea in patients undergoing pre-operative evaluation for bariatric surgery and referred to a sleep laboratory for polysomnography. J Bras Pneumol 2015;41:440–8.
4. Grau T, Leipold RW, Fatehi S, Martin E, Motsch J. Real-time ultrasonic observation of combined spinal-epidural anaesthesia. Eur J Anaesthesiol 2004;21:25–31. [CrossRef]
5. Eidelman A, Shulman MS, Novak GM. Fluoroscopic imaging for technically difficult spinal anesthesia. J Clin Anesth 2005;17:69–71.
6. Sahin T, Balaban O, Sahin L, Solak M, Toker K. A randomized controlled trial of preinsertion ultrasound guidance for spinal anaesthesia in pregnancy: outcomes among obese and lean parturients: ultrasound for spinal anesthesia in pregnancy. J Anesth 2014;28:413–9. [CrossRef]
7. Grau T, Leipold RW, Conradi R, Martin E, Motsch J. Efficacy of ultrasound imaging in obstetric epidural anesthesia. J Clin Anesth 2002;14:169–75. [CrossRef]
8. Kallidaikurichi Srinivasan K, Iohom G, Loughnane F, Lee PJ. Conventional Landmark-Guided Midline Versus Preprocedure Ultrasound-Guided Paramedian Techniques in Spinal Anesthesia. Anesth Analg 2015;121:1089–96. [CrossRef]
9. Lebbi MA, Trabelsi W, Bousselmi R, Messaoudi A, Labbène I, Ferjani M. Ultrasound-guided spinal anesthesia in an obese patient. Tunis Med 2014;92:164–6.
10. Whitty RJ, Maxwell CV, Carvalho JC. Complications of neuraxial anesthesia in an extreme morbidly obese patient for Cesarean section. Int J Obstet Anesth 2007;16:139–44. [CrossRef]