Have you ever thought of spinal/epidural in Dwarf pregnant

When you go to do neuro- axial block in Dwarf pregnant remember the following  10 points:

1-Dwarf patients have higher incidence of pelvic deformities,  they have higher incidence of C/S...so prepare yourself for shift from NVD to CS

2-Many dwarf patients suffer from pulmonary compromise, so they may not tolerate supine position while awake, and they may not tolerate the fluid preloading. Fluids should be given cautiously rather than large predetermined volumes. Patient with severe pulmonary compromise should be intubated.

3-Airway is Big problem in Dwarfs. They Have difficult airway (large occiput,atlantoaxial instability) and higher incidence of aspiration(BIG uterus in small abdominal cavity).So choose elective intubation rather spinal anesthesia if  you feel that patient airway will bring troubles.

4-Vertebral column is part of musculo-skeletal deformities. They have higher incidence of spinal stenosis, and difficult spaces, and surely have higher incidence of patchy epidurals...tell the patient ,"epidural may not work" and "many attempts may take place".

5-Smaller epidural space. Which mean higher incidence of wet tap..............go slowly

6-one shot spinal for C/S is not good choice...read 7 to know why

7-There is no dosage guideline for patients with short stature and abnormal spinal anatomy. With single shot spinal fears of over dosage may lead to inadequate analgesia and intraoperative discomfort ,while over dosage may lead to high spinal or total spinal. The better option is mentioned in the next point.

8-Epiural to be placed then augmented according to the anesthesia level is the better option, with careful increment of  dosage. And always prepare yourself for GA since failed block may occur....prepare the glidoscope and fiberoptic..."difficult airway"

9-Epidural Test dose may result in High spinal if the catheter was intrathecal. Again there is no clear guidelines, decreasing the dose may lead to false negative results. Giving the regular dose in divided fashion may solve this controversy.

10-Remeber GA and Regional are hazardous. Management plan should be always individualized

NB: Special Thanks to dr Ivan Colaizzi (Magee women’s hospital UPMC),who brought this topic to my attention

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