///2009 Abstract Details
2009 Abstract Details2018-05-01T17:45:11+00:00

A Case of High Spinal Blockade Through a Functioning Labor Epidural Catheter in a Patient with Harrington Rods

Abstract Number: 206
Abstract Type: Case Report/Case Series

Robert D Hilliard MD1 ; Jeanette Bauchat MD2; Cynthia Wong MD3

Introduction: High spinal blockade is rare with epidural catheters, reported at 0.07%.1 We report a high spinal blockade in a patient with Harrington rods who received 20 mL of 2-chloroprocaine 3%(2-CP) for urgent cesarean delivery(CS) through a functioning labor epidural catheter.

Case Report: A 22 yr old G1P0 woman presented in spontaneous labor with severe preeclampsia and a history of Harrington rod placement due to scoliosis. She had a midline scar from her neck to gluteal crease and no available radiologic films. An epidural catheter was placed on the 1st attempt at the L4-5 interspace. After negative aspiration, a test dose (lidocaine 1.5%/epinephrine 5 g/mL: 3 mL) ruled out intravascular and intrathecal placement. Analgesia was obtained with an additional 2 mL test dose, fentanyl 100 μg, and 10 mL bupivacaine 0.125%. A continuous infusion of bupivacaine 0.06%/fentanyl 2 μg/mL was initiated at 15 mL/h with a PCEA technique (bolus 5 mL, lock-out 10 min). She received 50 mL of this solution over 2.5 hours. She required a manual rebolus of 10 mL bupivacaine 0.125% resulting in analgesia and a T7 sensory level. One hour later 20 mL 3% 2-CP was administered via the epidural catheter (in 5 mL increments over 5 min) for anesthesia for CS due to fetal intolerance to labor. After delivery, 18 min following the start of this injection, the patient complained of dyspnea. Hoarse voice and absence of hand grasp were noted and her trachea was intubated. Respiratory parameters remained inadequate for extubation until 2.5 h after receiving the 2-CP 3% injection. She was discharged home with her infant following an uneventful postoperative course.

Discussion: Neuraxial techniques have been used safely in labor for patients with Harrington rods 2 despite the increased risk of multiple attempts, failure to place catheter, inadvertent dural puncture, subdural catheter placement, and unsatisfactory analgesia.3 Inadvertent intrathecal catheter placement in this patient is unlikely due to negative aspiration of CSF and no evidence of high spinal anesthesia with the initial loading dose (lidocaine 75 mg and bupivacaine 12.5 mg), nor the supplemental bolus of bupivacaine administered 1 h before the CS bolus. It is possible the epidural catheter migrated into the intrathecal space, although this is reported to occur in less than 0.2% of epidural procedures.1,4 Also, CSF could not be aspirated through the catheter before or after the high spinal event. It is possible that her back surgery created a scarred, noncompliant epidural space allowing an epidural catheter to function appropriately at low anesthetic volumes, but resulted in a high spinal anesthesia when a typical surgical anesthetic dose was injected into the epidural space. More research on this is needed and we recommend using caution with anesthetic dosing for CS in patients with Harrington rods.

References:

1.IJOA 1998;7:5-11

2.IJOA 2003;12:17-22

3.IJGO 1999;67:41-3

4.Anesthesiology 1991:75:452-6

SOAP 2009