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Total Spinal with Differential Block
Abstract Number: 225
Abstract Type: Case Report/Case Series
Introduction: We describe the presentation and anesthetic management of a patient with an intrathecal catheter and C2 sensory level who does not experience significant motor blockade.
Case: A 21 year-old G1P0 African-American female at term with a history of chronic hypertension presented to the hospital in labor. Our anesthetist placed an epidural catheter without difficulty, with a negative aspiration for CSF, and dosed it with 3ml of lidocaine 1.5% with 1:200k epinephrine. This test dose was negative; he then dosed the epidural with 10 ml of a solution consisting of .08% bupivacaine and a total of 116 mcg fentanyl. The patient became comfortable, and was started on an infusion of .0825% bupivacaine with 2mcg/ml fentanyl at 8ml/hr. The obstetricians then began an infusion of cefazolin for the patient's ruptured membranes; she is allergic to penicillin. The anesthesia fellow was called 20 minutes after epidural placement for complaints of "I can't swallow".
Upon entering the room, the fellow stopped the cefazolin and bupivacaine infusions and examined the patient. She was drowsy but agitated, and complained "I can't swallow." Upon examination, the patient was normotensive and had 4/5 strength in 4 extremities. She swallowed normally to palpation, but reported that she wasn't "swallowing properly". Airway exam was normal and non-edematous; the obstetrician administered diphenhydramine. Sensory testing was initiated, and the patient was discovered to have a C2 sensory level. Aspiration of the epidural catheter obtained CSF.
The patient became increasingly drowsy, but followed commands and retained 4/5 strength in all extremities. The fellow, doula, and husband remained in the delivery room and alternated the task of verbally stimulating the patient. She lost her ventilatory drive, but would breathe on command; at no point did she lose motor function in any extremity. Pulse oximetry was used; the patient was not given supplemental oxygen. The spinal anesthetic proved sufficient to perform arterial blood gases without any pain; before recovery she had an ABG of 7.35/41/169/22.
Nearly 2 hours after epidural placement, the patient became fully awake; shortly thereafter she was able to delivery a healthy infant. She required one additional intrathecal bolus of bupivacaine for labor pain during her stay. She did not experience a spinal headache afterwards.
Discussion: It is reported that the volume of bupivacaine used in a spinal does not affect the level obtained; however, the studies demonstrating this do not use volumes of 13 ml. Using a low concentration solution of epidural bupivacaine may allow a degree of safety that more concentrated epidural solutions do not offer: this patient did not experience motor blockade despite a high dose of bupivacaine/lidocaine and a high sensory spinal level. If apnea is avoided and a patient is able to protect her airway, intubation may be unnecessary despite a total spinal.