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Acute Respiratory Failure During Urgent Cesarean Section After Dosing A Previously Functioning Labor Epidural
Abstract Number: RF4AD-475
Abstract Type: Case Report Case Series
Acute respiratory failure is a serious perioperative complication for cesarean sections with a wide differential. We will discuss a case of acute respiratory failure during urgent cesarean section, likely from a complication of neuraxial anesthesia.
We discuss the case of a 26 year old G1P0 female at 41 weeks of gestation who developed acute respiratory failure during an urgent cesarean section. The patient was admitted for post dates induction of labor. She requested epidural placement for labor analgesia. Placement was difficult, requiring 4 attempts. The epidural was initially loaded with 14 mL of bupivacaine 0.125% and 50 mcg of fentanyl. The patient required treatment for hypotension 1.5 hours after epidural placement but was otherwise comfortable with an epidural infusion of bupivacaine 0.083% and fentanyl 10 mcg/mL at 12 mL/h. She was taken to the operating room 16 hours after epidural placement for urgent cesarean section due to arrest of descent and a non-reassuring fetal tracing. The epidural was dosed on the way to the operating room with 10 mL of 2% lidocaine with epinephrine and bicarbonate in divided doses following negative aspiration of the catheter. Upon transfer to the OR bed, the patient started to mouth “I can’t breathe” without making any sound and holding her hands to her throat. She desaturated to the 60s and became cyanotic and unresponsive. She was mask ventilated and general anesthesia was induced for STAT delivery. Intubation with a C-MAC D blade was unsuccessful and an LMA was placed with adequate ventilation and rapid improvement in saturation. She began initiating breaths 4 minutes after LMA placement. She required methylergonovine maleate and tranexamic acid for uterine atony but remained hemodynamically stable. The remainder of her procedure was uneventful, and the LMA was removed with no issues. She was initially transferred to the SICU following delivery but was quickly moved back to the floor. An extensive workup was undertaken that included non-contributory lab studies, chest radiograph, and transthoracic echocardiogram.
Our differential included a high spinal, subdural injection, laryngospasm or other upper airway obstruction, anaphylactoid syndrome of pregnancy, anaphylaxis, and pulmonary embolism. In the absence of any definitive reason for her respiratory failure, we believe that either a dural tear resulting from a challenging epidural placement or subdural placement of the epidural can explain her sudden apnea. The patient’s ability to move her arms while being apneic and her rapid recovery of spontaneous ventilation are features that we cannot fully explain but make this case even more challenging and interesting.
During this case presentation, we highlight the differential diagnosis of acute respiratory failure during labor and cesarean section and the airway challenges of pregnancy. We also review the literature and discuss the use of LMAs for cesarean section.