BROKEN SPINE, UNSHAKEN SPIRIT – TIVA IN EARLY PREGNANCY FOR TRAUMATIC SPINAL INJURY FIXATION IN RURAL SRI LANKA
C P Welagedara, F S Mohamed Rauf, C Y Abeywardana FRCA
Department of Anaesthesia & ICU - Teaching Hospital Polonnaruwa, Sri Lanka

Introduction:
Traumatic spine injury with compromised neurology necessitate early operative intervention as the injuries are time critical. We describe a successful spinal injury fixation under Total Intravenous Anaesthesia (TIVA) in first trimester of a parturient leading to a successful pregnancy and delivery in a rural hospital in Sri Lanka.

Case Report:
A 24 year old G3P2C2 with a POA of 9 weeks was transferred to a rural peripheral hospital following a road traffic accident. She had complete loss of left lower limb motor power with intact sensation. Right limb was unaffected. Radiographs revealed T12 & L1 vertebral fracture dislocation. A transabdominal ultrasound revealed a normal viable foetus. A multi-disciplinary team recommended urgent fixation of the spine in prone position. Invasive arterial monitoring was established. The hospital had only one TIVA capable syringe pump and BIS monitoring was unavailable. Patient was anaesthetized via a fixed dose Remifentanil infusion 20-40mcg/kg/hr and target-controlled Propofol infusion (2.5-4 mcg/ml) with effect-site monitoring using Schnider model. She was intubated with a 6.5mm reinforced endotracheal tube. Patient was proned carefully with the abdomen allowed to hang freely. Blood pressure was maintained with IV Phenylephrine infusion. T11/T12 & L1/L2 Transpedicular fixation & L1 relocation was performed under image intensifier guidance and bilateral Erector-spinae (ESP) catheters were placed for analgesia. Post-operative period was uneventful. Left leg motor function improved postoperatively. Foetal viability was confirmed. She gave birth to a healthy baby girl at 37 weeks through vaginal delivery.

Discussion:
General anaesthesia in first trimester carries a high miscarriage risk and can adversely affect foetal neurodevelopment.^1,2 Pregnancy augments haemodynamic effects of prone position which were less pronounced in this patient due to lower gestational age. Although Schnider model is not licensed in pregnancy, careful observation of effect-site concentration at loss of verbal response helped maintain an adequate depth of anaesthesia. Phenylephrine was used to support placental perfusion due to favourable foetal acid-base profile.¹ ESP catheters improved postoperative analgesia and reduced opioid requirement. NSAIDS were avoided due to possible adverse foetal effects.¹ This case report underscore the importance of improvising anaesthetic approach when making time-critical decisions in a resource limited setting.

References:

2.Bleeser T, Van Der Veeken L. Effects of general anaesthesia during pregnancy on neurocognitive development of the fetus: a systematic review and meta-analysis. British Journal of Anaesthesia. 2021 Jun;126(6):1128–40.