Spinal Anesthesia for Emergency Open Appendectomy During Pregnancy at 22 Weeks with Perforated Appendicitis: A Case Report

Abstract

Neuraxial anesthesia can avoid airway instrumentation in selected patients; however, its use in emergency open abdominal surgery is uncommon and requires a clearly established plan for conversion to general anesthesia. Clinical examination revealed focal signs of peritoneal irritation, with an Alvarado score of 7–8. The patient presented with tachycardia but remained normoxemic and hemodynamically stable. Laboratory investigations revealed neutrophilic leukocytosis and ketonuria. An emergency open appendectomy was planned for suspected perforated appendicitis. The patient was classified as American Society of Anesthesiologists (ASA) Physical Status II E. Given the incomplete fasting period, pregnancy-related airway changes and an increased risk of aspiration were considered in preparing a contingency plan for general anesthesia. Following intravenous fluid resuscitation, single-shot spinal anesthesia was administered at the L2–L3 interspace using a 27-gauge Quincke needle, with 10 mg of bupivacaine and 25 ?g of fentanyl administered intrathecally. A sensory block extending to the T4–T6 dermatomes was targeted. The patient remained awake without sedation, received supplemental oxygen via nasal cannula at 3 L/min, and was positioned supine with a slight left lateral tilt to minimize aortocaval compression. Transient hypotension occurred following spinal anesthesia, with a lowest recorded systolic blood pressure of 90 mmHg, and was managed with 10 mg of intravenous ephedrine. No episodes of bradycardia or oxygen desaturation were documented. The surgical procedure lasted 90 minutes, during which a perforated appendix with peritonitis was confirmed. Fetal cardiac activity remained stable on Doppler assessment before and after surgery. Postoperative recovery was uneventful, with a pain score of 1/10 in the postanesthesia care unit, and the patient was discharged on postoperative day 3. Single-shot spinal anesthesia provided adequate surgical conditions for a 90-minute emergency open appendectomy in this carefully selected, hemodynamically stable patient at 22 weeks of gestation. However, this favorable outcome does not establish the superiority of spinal anesthesia over general anesthesia.