2026 SOAP Annual Meeting

When Neuraxial is a No-No: General Anesthesia for a Parturient with Heart Failure and Cerebral Midline Shift

Taylor Catalano, MD & Hannah Jennings-Davis, MD

Background

•Neuraxial anesthesia is preferred during cesarean delivery

•Decreases risk of aspiration

•Provides postoperative pain control

•Avoids potential intubation difficulty

•Allows for maternal wakefulness during birth

•Caution needed in patients with intracranial pathology

•Risk of cerebrospinal fluid leak, cerebral hypoperfusion, and herniation

Case Presentation

Patient: 32-year-old G9P3235 with:

•Non-ischemic cardiomyopathy (LVEF nadir 20-25%)

•Congenital arachnoid cyst

•Chronic subdural hematoma with mass effect and midline shift (new since prior delivery)

•Polysubstance use

•Two prior cesarean deliveries with neuraxial anesthesia

Procedure: Cesarean delivery at 36 weeks

Anesthetic Plan: General anesthesia

•Access: 2 peripheral IVs and 1 pre-induction arterial line

•Induction: Rapid sequence intubation with video laryngoscopy

•Maintenance: Propofol infusion

•Hemodynamic Management: Clevidipine for intraoperative hypertension

•Pain control: Fentanyl, Acetaminophen, Ketorolac, Bilateral transverse abdominis plane blocks with liposomal bupivacaine

Outcome and Take-Home Point

Outcome

•Uncomplicated intubation, anesthetic, and extubation

•Cesarean delivery performed without complication (quantitative blood loss of 392 mL)

•Post-operative pain well-controlled with scheduled acetaminophen and ibuprofen and as-needed oxycodone

•Patient was discharged on post-operative day 5

Take-Home Point

•While neuraxial anesthesia is preferred for cesarean delivery, the presence of increased intracranial pressure warrants careful preoperative evaluation and planning to ensure patient safety

2026 SOAP Annual Meeting

When Neuraxial is a No-No: General Anesthesia for a Parturient with Heart Failure and Cerebral Midline Shift

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