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High block after epidural: subarachnoid injection or subdural?
Abstract Number: SU-56
Abstract Type: Case Report/Case Series
High/total spinal is a known complication of neuraxial block. Unintentional subdural blockade, still remains a less recognized complication, often mistaken as inadvertent subarachnoid injection or epidural catheter migration. We present a case of a parturient where an unexpected, delayed high block was achieved, following administration of medications through the epidural catheter.
Case: 26 years female admitted for induction of labor for severe IUGR and pre-eclampsia. Patient was started on Magnesium for seizure prophylaxis. CSE was performed uneventfuly. One hour later, patient required additional analgesia but there was no relief. Decision was made to repeat the epidural block. Epidural catheter was placed successfully. Catheter aspiration and test dose were negative. A slow bolus of 20ml of 0.125 bupivacaine was administered over 20 minutes at which time patient stated relief. Epidural infusion was started. Patient then became nauseous, blood pressure stable, but fetal bradycardia was noted. Phenylephrine bolus and supplemental oxygen were administered. Minutes later fetal bradycardia was again noted. We positioned the patient on her lateral side, her response was sluggish, still responding to command, but extremely lethargic. Epidural infusion was immediately stopped. Catheter aspirated and was positive for CSF. Bradycardia did not improve and decision was made to perform STAT C-Section. Upon arrival to the OR patient was unresponsive and started to desaturate. We immediately intubated her and C-Section was performed. Spontaneous ventilation returned within a minute and vital signs remained stable throughout the case. Patient was extubated at the end of the case without sequela. On POD#2, patient complained of positional headache, not responding to conservative management and epidural blood patch was performed. Headache resolved and patient went home.
Discussion: Accidental subdural block can occur during the performance of either epidural or spinal block, incidence varying from 0.82% to 7%. Subdural drug deposition can result in unpredictable, varying sympathetic,sensory and motor block and often involves cranial nerves. Hence, it remains a poorly understood and diagnosed clinical entity. Awareness, strict vigilance and timely intervention is essential to avoid potentially critical complications.
Lubenow et al described 2 major and 3 minor clinical criteria for the diagnosis of subdural block. Major criteria included a negative aspiration and extensive sensory block; minor criteria included delayed onset by 10 minutes, minimal motor block and disproportionate sympatholysis.
A subdural catheter can easily perforate the thin arachnoid membrane and become an intrathecal catheter. Understanding the complexity and presentation of a subdural block is crucial in identifying an accidental subdural catheter placement and treating the patient accordingly.
Anesthesia and Intensive Care 2010,Vol 38,No1
Open Journal of Anesthesiology 2012.