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Severe Bronchospasm Treated with Endotracheal Epinephrine during a Scheduled Repeat Cesarean Delivery and Tubal Ligation
Abstract Number: SU-35
Abstract Type: Case Report/Case Series
Introduction: Bronchospasm under regional anesthesia is a rare event, if unrecognized, could result in fatal outcomes. In parturients undergoing elective surgery,it is even more unusual. Bronchospasm is reported as 2% under regional anesthesia vs. 6.4% under general endotracheal anesthesia in the asthmatic population(1). When encountered, if the condition is resistant to traditional treatment modalities, endotracheal epinephrine can be a lifesaving measure.
Case: Our patient is a 28 yo F G3P2 at 39 wga who presents for a scheduled repeat cesarean delivery and tubal ligation. Her medical history consists of obesity, mild-intermittent asthma, and a vague cardiac condition without follow up (due to a lack of symptoms). Allergies include: peanut products, eggs, tetanus toxoid, and seafood. Preoperative workup and physical exam were unremarkable. A surgical CSE was performed followed by an uneventful delivery. Soon after delivery, patient became agitated, pruritic, and dyspneic. No visible rash was seen, but new bilateral expiratory wheezes were appreciated on exam.
Sudden hypotension, hypoxia and unresponsiveness prompted swift intubation and aggressive resuscitation. Despite confirmed ETT placement and patency, airway pressures of >40mmHg, hypoxia and hypotension persisted. Treatment was resistant to IV epinephrine, Albuterol, Diphenhydramine, and Dexamethasone. Ultimately,endotracheal epinephrine was given and resistance to ventilation and respiratory mechanics dramatically improved. The differential diagnosis for bronchospasm included: asthma, anaphylaxis, and amniotic fluid embolism. The patient was transferred intubated with hemodynamic support to the SICU. Despite a tumultuous intraoperative course, she was weaned off vasopressors and extubated the same day. Extensive workup in the ICU did not reveal a definitive etiology.
Discussion: Endotracheal epinephrine was an effective measure in our patient’s resuscitation. Because epinephrine is a potent beta agonist, it can potentially result in better delivery to the respiratory smooth muscle resulting in bronchodilation when given endotracheally (3). Endotracheal epinephrine’s efficacy has been demonstrated in a case report of a 13 yo boy with an acute refractory asthma attack as well as in the canine model (3)(4).
Though rare, bronchospasm under neuraxial may happen unexpectedly; thus, practitioners should be aware of its safe management. In cases of severe bronchospasm, endotracheal epinephrine, an often overlooked treatment modality, can be lifesaving.
1.) Wang C et al. Anesthesia.(1993 )48:514-515
2.) Kasaba et al. Masui (2000) Oct: 1115-20
3.) Liebman. American Journal of Emergency Medicine. (1997) Jan 15:106
4.) Greenberg et al. JACEP. (1979) Dec: 500-503