What is the best anesthesia option for a patient with quadriplegia undergoing a cesarean section (CS) and are there any special precautions?

Anesthesia Management for Cesarean Section in a Patient with Quadriplegia

Patients with quadriplegia undergoing cesarean section require neuraxial anesthesia, with spinal anesthesia being the preferred technique, as they still need anesthesia for the surgical procedure despite their neurological condition. 1

Understanding Anesthesia Needs in Quadriplegic Patients

Patients with quadriplegia still require anesthesia for cesarean section for several important reasons:

1. Surgical stimulation occurs below the level of spinal cord injury
2. Incomplete lesions may allow some sensation
3. Autonomic hyperreflexia risk requires prevention
4. Psychological comfort during surgery is essential

Recommended Anesthetic Approach

Primary Recommendation: Neuraxial Anesthesia

Neuraxial anesthesia is strongly recommended as the first-line approach for cesarean section in quadriplegic patients 1, 2:

• Spinal anesthesia with intrathecal morphine 50-100 μg or diamorphine 300 μg is the preferred technique
• If using an epidural catheter (e.g., as part of combined spinal-epidural), epidural morphine 2-3 mg or diamorphine 2-3 mg is recommended

Multimodal Analgesia Components

For optimal pain management, include:

• Pre-operative oral paracetamol
• Post-delivery intravenous paracetamol if not given pre-operatively
• Intravenous NSAIDs after delivery
• Single dose of intravenous dexamethasone after delivery
• If intrathecal morphine not used, consider:
  • Local anesthetic wound infiltration
  • Continuous wound local anesthetic infusion
  • Fascial plane blocks (TAP or quadratus lumborum blocks)

Special Precautions for Quadriplegic Patients

1. Autonomic Dysreflexia Prevention:

   • Ensure adequate anesthetic block height (T4 dermatome)
   • Monitor for sudden hypertension, bradycardia, and headache
   • Have vasodilators readily available

2. Respiratory Considerations:

   • Assess baseline respiratory function pre-operatively
   • Consider lower doses of neuraxial opioids if respiratory compromise exists
   • Have emergency airway equipment immediately available

3. Hemodynamic Management:

   • Anticipate exaggerated hypotension with neuraxial anesthesia
   • Prepare vasopressors (phenylephrine preferred)
   • Consider pre-loading with crystalloid fluids

4. Thermoregulation:

   • Monitor temperature closely
   • Use warming devices as quadriplegic patients have impaired thermoregulation

5. Positioning:

   • Careful positioning to prevent pressure injuries
   • Pad all pressure points thoroughly
   • Avoid excessive neck manipulation if high cervical injury

General Anesthesia Considerations (If Neuraxial Contraindicated)

General anesthesia should be reserved only for cases where neuraxial techniques are contraindicated 2, 3:

• Use rapid sequence induction with propofol and rocuronium
• Consider remifentanil for intubation and maintenance
• Maintain anesthesia with volatile agents at >0.7 MAC to prevent awareness
• Consider switching to propofol maintenance if uterine atony develops

Postoperative Management

• Regular paracetamol and NSAIDs as baseline analgesia
• Opioids for rescue analgesia only
• Consider transcutaneous electrical nerve stimulation as an adjunct
• Monitor for respiratory depression if neuraxial opioids were used
• Implement extended thromboprophylaxis due to increased VTE risk

Surgical Technique Recommendations

For optimal outcomes, the surgical team should consider:

• Joel-Cohen incision technique
• Non-closure of the peritoneum
• Use of abdominal binders

By following this evidence-based approach to anesthesia management for cesarean section in quadriplegic patients, you can ensure optimal maternal outcomes while minimizing complications related to the patient's underlying neurological condition.