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///2018 Abstract Details
2018 Abstract Details2019-08-02T15:57:01-05:00

Respiratory Failure due to Total Spinal Anesthesia vs. Exacerbation of Underlying Pulmonary Process

Abstract Number: F3D-9
Abstract Type: Case Report/Case Series

Akeel M Merchant MD1 ; Akeel M Merchant MD2; Dawood Nasir MD3; Michelle M Eddins MD4

Introduction

Total spinal anesthesia (TSA) is a known complication of neuraxial anesthesia with incidence of 0.02% in obstetrics patients. Common signs and symptoms include bradycardia, hypotension, dyspnea, loss of consciousness and respiratory depression. It is important in patients with underlying respiratory process receiving neuraxial anesthesia to be able to distinguish between TSA and an exacerbation of their underlying processes. We present a case of a patient in respiratory distress in the setting of influenza with superimposed pneumonia developing respiratory failure following spinal anesthesia requiring intubation prior to C-section.

Case Report

A 22 year old G2P0A1 with no pertinent past medical history presented at 39 weeks for induction of labor following premature rupture of membranes. She had complaints of dry cough and mild sore throat for 1 day. She was empirically started on oseltamivir and was found to have influenza type A. The patient received an L3-4 lumbar epidural for her labor with adequate level. Over the course of the day she developed low grade fever, myalgia, tachycardia and desaturation requiring supplemental oxygen. She was found to have WBC of 1.04 and was started on empiric antibiotics for chorioamnionitis. Due to failure to progress and augment she was taken to the OR for an urgent C-section.

The anesthesia provider was not confident that the labor epidural would dose up appropriately for cesarean section, so patient was administered spinal anesthesia with 1.6ml of 0.75% bupivacaine and 20mcg of fentanyl at L3-4 level following removal of the epidural catheter. Patient subsequently complained of shortness of breath and had desaturations to 40s with non-reassuring fetal heart rate requiring intubation and emergent C-section under general anesthesia. The patient remained on 100% FiO2 for low saturations throughout the case and was transferred to the ICU intubated. Her postoperative course was complicated by acute respiratory failure in the setting of influenza with superimposed pneumonia, hemorrhagic shock due to grade II splenic laceration requiring splenectomy, septic shock from chorioamnionitis, peripartum cardiomyopathy, AKI, and a readmission for bilateral pulmonary emboli.

Conclusions

Determining whether respiratory failure is a result of TSA or an underlying pulmonary process is important as it can have ramifications on airway management, necessity of adjuvant therapy and timing of extubation. In the above case, the patient continued to have significant respiratory distress during her perioperative course making TSA unlikely as the cause of her respiratory failure. From this case, it may reasonable to conclude that patients in respiratory distress rely more heavily on the accessory muscles of respiration, and, therefore, should receive a lower than average spinal dose for C-section.

Reference

Chestnut, David H. Chestnut's Obstetric Anesthesia: Principles and Practice. Elsevier/Saunders, 2014.

SOAP 2018