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Maternal cardiac arrest following high neuraxial block

Authors:

Samadara Manel Kumari Weerasuriya ,

GB
About Samadara
Staff grade anaesthetist,Anaesthetic Department,Princess Royal University Hospital,King's College Hospital, London.
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R Addison,

GB
About R
Consultant, Anaesthetic Department,Princess Royal University Hospital,King's College Hospital, London.
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P Sri Ganeshan

GB
About P
Consultant, Anaesthetic Department,Princess Royal University Hospital,King's College Hospital, London.
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Abstract

Introduction

Maternal cardiac arrest is one of the most dreadful experience for patient and anaesthetist. Prompt and vigilant management including perimortem caesarean delivery (PMPD) contributes to maternal and foetal wellbeing. We present an Obstetric case report of maternal cardiac arrest following high neuraxial blockade.

Case Report

33 year old primigravida, ASA 2 in established labour had an epidural catheter insertion for labour analgesia .It was straight forward, first attempt procedure with no evidence of dural puncture-confirmed by siphoning test and negative aspiration test. Six hours later she needed to undergo emergency caesarean section and the epidural was topped up in the theatre with 0.5% levo-bupivacaine and 2% lignocaine(total of 20ml). Soon afterwards, she complained of difficulty in breathing and showed absence of hand grip and loss of cold sensation to ethyl alcohol below the clavicle. Anaesthetist declared it as a high block,  immediately called for help and prepared for intubation. Within seconds, she became cyanosed and emergency management was commenced. Airway was secured, though with difficulty, CPR commenced quickly. As the event was related to local anaesthetic administration, intralipid also was given. In parallel, obstetric team commenced PDPM immediately and in 2 minutes to the event, delivered a live, non-asphyxiated baby who cried at birth. After further 2 minutes of CPR maternal cardiac output regained. Since then, the patient’s monitored parameters were stable and no inotropes/ vasopressors were required .At the end of the surgery, patient was able to maintain spontaneous breathing. While decisions were made to admit her to the ICU, she was extubated awake. Amazingly, she was conscious, oriented and was talking appropriately and was pain free.(Neuraxial block had decent though still working).She spent few hours in the ICU under close monitoring and returned to the Obstetric unit. Later discussions revealed that she remembered only the last few words before losing the cardiac output and there was no awareness. After two days, she presented with severe headache which was successfully treated with epidural blood patch for Post Dural Puncture Headache (PDPH).

Discussion

Subdural migration of extradural catheter is a recognized complication. In some studies it was confirmed by radiological evidence. Though this was not done on our patient, the clinical picture, rapidity of block onset and later presentation with PDPH favour the diagnosis. It is possible even some local anaesthetic was washed into the intrathecal compartment through unrecognised accidental dural puncture. This case highlights

DOI: http://dx.doi.org/10.4038/slja.v22i2.6687

How to Cite: Weerasuriya, S.M.K., Addison, R. & Sri Ganeshan, P., (2014). Maternal cardiac arrest following high neuraxial block. Sri Lankan Journal of Anaesthesiology. 22(2), pp.67–68. DOI: http://doi.org/10.4038/slja.v22i2.6687
Published on 27 Jun 2014.
Peer Reviewed

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