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Methods for Improving the Management of High Regional Block in Obstetrics
Abstract Number: F-43
Abstract Type: Case Report/Case Series
Introduction: High spinal is a rare complication during labor epidural placement, with the reported incidence ranging from 0.006% (Jenkins 2005) to 0.02% (Crawford 1985). Though infrequent, the adverse effects have far-reaching consequences, harming both mother and fetus.
Case Description: A 24 y.o. G2P1 at 39 weeks gestation presents to L&D in early labor. On the first epidural attempt, the epidural space is located at 8 cm using a LOR to saline. Aspiration and test dose is negative. Upon removing the sterile drape, the epidural catheter is inadvertently removed, and thus, the resident attempts epidural placement again. Again, the epidural space is 8 cm in depth, and the catheter threads easily. A second test dose is negative (no change in HR, no paresthesias). The epidural catheter is bolused. Ten minutes later, the patient’s BP is noted to be 10% below baseline, and a fluid bolus is started. Twenty minutes after the second test dose, anesthesia evaluates the patient who complains of breathlessness. The patient becomes less responsive and stops breathing. A high spinal is diagnosed. Intubation is performed at the bedside, bilateral breath sounds are auscultated, and fogging is noted in the ETT. No end-tidal carbon dioxide detector is available. Fetal HR in the 80’s is noted. The patient is transferred to the OR for an emergent C-section. The baby weighs 3070 g with Apgars of 8 and 9. The patient is reintubated in the OR for persistent hypoxia and receives one round of ACLS with epinephrine for PEA. A post-op MRI is performed in the ICU to evaluate for ischemic encephalopathy.
Discussion: The first area of improvement would be to create a teaching algorithm to be displayed on epidural carts, which could be utilized in training residents.
In addition, the use of team-based training could be quite beneficial in such scenarios. Simulation has been shown to improved adverse outcomes by 37% in the obstetric population (Riley 2011). The nursing staff was not familiar with the location of airway supplies in the code blue cart. Succinylcholine was requested, but not available at the bedside. There was difficulty in locating the carbon dioxide detector. All of these incidents point to a common theme – the need for multi-disciplinary mock drills.
Conclusion: High spinal block is just one of several emergency situations. Learning algorithms and participating in mock code drills provide knowledge and practice in emergency situations.