///2010 Abstract Details
2010 Abstract Details2019-08-03T15:49:10-05:00

Total Spinal in a Parturient with Acute Lymphocytic Leukemia Undergoing Repeat Cesarean Delivery

Abstract Number: 171
Abstract Type: Case Report/Case Series

Terel Newton M.D.1 ; Kathleen Smith M.D.2; Fred Spielman M.D.3

INTRODUCTION: We describe the first report of a total spinal in a patient receiving intrathecal methotrexate (MTX) for acute lymphocytic leukemia (ALL) following administration of a spinal anesthetic.

CLINICAL FEATURES: A 27 yo G4 P1021 female (96 kg, BMI 31.3 kg/m2) at 30 wks gestation presented for scheduled repeat c-section. The patient recently finished her first course of intrathecal MTX, for newly diagnosed ALL. Delivery was scheduled to allow for further treatment of her disease.

A combined spinal-epidural technique was chosen. After sterile preparation and draping, the block was placed with difficulty requiring several attempts. A 17g Touhy needle was advanced with loss of resistance to air at 4.5 cm at L 2-3 interspace. A 27g spinal needle was advanced with return of clear CSF. Intrathecal isobaric bupivicaine (11 mg), fentanyl 10 mcg, and preservative free morphine 100 mcg were given. An epidural catheter was advanced to 9.5 cm, with no return of CSF. A phenylephrine infusion was started at 60 mcg/min. The patient was placed supine with left uterine displacement after injection of the medications and supplemental oxygen was applied. Once supine, the patient reported dyspnea, worsening anxiety, and numbness extending to her fingers and face. Phonation was decreased, bilateral grip strength was poor, and the patients tidal volumes were <200 ml with application of 100% oxygen via bag-mask. Oxygen saturation was maintained at 99% and her blood pressure was 148/101 with heart rate in the 90s. Level of consciousness was preserved. The decision was made to proceed with general anesthesia due to high subarachnoid block. The patients breathing was assisted with simultaneous bag-mask ventilation and cricoid pressure. Rapid sequence induction was performed with propofol 200mg and succinylcholine 100mg, and the trachea was intubated with confirmation by sustained end-tidal CO2, bilateral chest rise and equal breath sounds. Anesthesia was maintained with sevoflurane. Following delivery, midazolam 2mg IV, fentanyl 40mcg IV and 50% nitrous oxide were given.

Vital signs remained stable throughout and phenylephrine was weaned off 40 mins after spinal placement. The patient was uneventfully extubated at the end of the surgery and transported to the PACU in stable condition.


Intrathecal MTX is known to increase serum protein permeability of the blood-CSF barrier. If this change increases CSF density, local anesthetic (LA) hypobaricity will be increased and there will be greater spread of LA in the subarachnoid space, placing a patient at risk for high subarachnoid block. Currently, no studies evaluate the effects of intrathecal MTX and chemotherapy on the density of CSF, making it difficult to rule this out as the cause of a total spinal. Decreased density of spinal injectate from the addition of opioids, prolonged sitting position after dosing of isobaric LA, and decreased LA requirement in pregnancy may have also played a role.

SOAP 2010