///2009 Abstract Details
2009 Abstract Details2019-08-03T15:55:31-06:00

Chemical Meningitis Following Presumed Epidural Placement

Abstract Number: 236
Abstract Type: Case Report/Case Series

Elyssa Pohl MD1 ; Farheen Mirza MD2; Alan Santos MD3; Sanford Littwin MD4

Neurological complications following regional analgesia for labor are rare but may include post-dural puncture headache, total spinal anesthesia, meningitis, epidural hematoma/abscess, anterior spinal artery syndrome, intravascular injection, cauda equina syndrome, subdural catheter placement and transient radicular irritation. The most common complication is post-dural puncture headache occurring in up to 2.6% of parturients undergoing epidural anesthesia. We describe a case of an unexpected high spinal level, possible subdural catheter position and probable chemical meningitis.

Case: A 28-year old G3P2 woman at 1 cm dilation requested labor analgesia. An epidural catheter was placed with negative aspiration of blood or CSF. A test dose of 1.5% lidocaine with 1:200K epinephrine for intrathecal or intravascular placement was given. No symptoms were elicited. A bolus dose of 1/8% bupivicaine was then administered. Within 10 minutes, the patient began to describe symptoms consistent with a high spinal block indicated by upper extremity weakness, numbness and dyspnea. Supportive care was initiated and within the next 45 minutes symptoms diminished. An infusion of 0.0625% bupivicaine plus fentanyl was started at 2ml/hr and the patient continued to labor. Five hours later patient complained of worsening labor pain. This first catheter was removed and a CSE was performed at the same level wherein labor continued uneventfully with the subsequent delivery of a healthy baby girl. Six hours postpartum, the patient then developed clinical symptoms consistent with meningitis including nonpostural headache, nuchal rigidity, photophobia and a fever of 101.3 degrees. A full work up was performed including head CT and lumbar puncture. CSF findings were suspicious for bacterial meningitis (low glucose/high protein/moderate WBCs). The patient was treated with IV vancomycin, ceftriaxone and ampicilin. MRI demonstrated plial thickening indicative of meningitis. ID consultation determined symptoms were consistent with chemical meningitis. Patient was started on IV steroids with amelioration of all symptoms within 24 hours. Final CSF cultures were negative.

Discussion: The causes of headache after post-dural puncture are most often related to CSF leak. However, infectious etiologies and vascular abnormalities may also occur. We report a case of initially suspected bacterial meningitis that did not respond to conventional treatment. Steroid treatment successfully resolved her symptoms. The most likely cause was chemical meningitis due to an initial subdural catheter placement and infusion of local anesthetic within the subdural space. The multifactorial clinical picture in this patients anesthetic course was likely due to the meningeal irritation and relative "high spinal" all caused by the deposition of local anesthesia in this pseudo-space. In this case, the patients symptoms resolved with a short course of steroids with no subsequent sequela.

SOAP 2009