Intermittent loss of consciousness during cesarean section under spinal anesthesia: a case report / Perda intermitente de consciência durante cesariana sob raquianestesia: relato de caso

Abstract Loss of consciousness during spinal anesthesia is a rare but scary complication. This complication is generally related to severe hypotension and bradycardia, but in this case, the loss of consciousness occurred in a hemodynamically stable parturient patient. We present a 31 years-old patient who underwent an emergency cesarean section. She lost consciousness and had apnea that started 10 minutes after successful spinal anesthesia and repeated three times for a total of 25 minutes, despite the stable hemodynamics of the patient. The case was considered a subdural block, and the patient was provided with respiratory support. The subdural block is expected to start slowly (approximately 15-20 minutes), but in this case, after about 10 minutes of receiving anesthesia, the patient suddenly had a loss of consciousness. After the recovery of consciousness and return of spontaneous respiration, the level of a sensory block of the patient, who was cooperative and oriented, was T4. There were motor blocks in both lower extremities. Four hours after intrathecal injection, both the sensory and motor blocks ended, and she was discharged two days later with no complications. Hence, patients who receive spinal anesthesia should be closely observed for any such undesirable complications.

Resumo A perda de consciência durante a raquianestesia é uma complicação rara, mas assustadora. Essa complicação geralmente está relacionada à grave hipotensão e bradicardia, mas, neste caso, a perda de consciência ocorreu em uma paciente parturiente hemodinamicamente estável. Apresentamos o caso de uma paciente de 31 anos, submetida a uma cesariana de emergência. A paciente perdeu a consciência e apresentou apneia que teve início 10 minutos após a raquianestesia bem-sucedida e repetiu o episódio três vezes por 25 minutos, a despeito de sua hemodinâmica estável. O caso foi considerado como um bloqueio subdural e a paciente recebeu suporte respiratório. Espera-se que o bloqueio subdural inicie lentamente (aproximadamente 15-20 minutos), mas, neste caso, cerca de 10 minutos após a anestesia, a paciente repentinamente perdeu a consciência. Após a recuperação da consciência e o retorno da respiração espontânea, a paciente que estava orientada e cooperativa apresentou nível de bloqueio sensorial em T4. Havia bloqueio motor em ambas as extremidades inferiores. O bloqueio sensório-motor terminou quatro horas após a injeção intratecal e a paciente recebeu alta hospitalar dois dias depois, sem complicações. Considerando o exposto, os pacientes que recebem raquianestesia devem ser atentamente observados para quaisquer complicações indesejáveis.

Accidental Subdural Block during Epidural Anesthesia: A case report / 대한마취과학회지

Despite the high incidence of subdural block (SDB) during epidural anesthesia, the condition is unfamiliar to anesthesiologist. We experienced a case of SDB: severe hypotension, transient hemiplegia, wide extent of block and late onset and recovery from block. The case described is an examples of SDB and should remind anesthesiologist of the clinical course and treatment.

Cardiac Arrest following Epidural Block for Postoperative Pain Control / 대한마취과학회지

The continuous epidural anesthesia is an effective method for postoperative pain control and improvement of pulmonary function. A 39-year-old man was scheduled for postoperative intestinal obstruction. After adhesiolysis under the general anesthesia, epidural anesthesia was done for postoperative pain control. Because an accidental dural puncture was noticed, the adjacent interspace of epidural anesthesia was tried and catheter was inserted. Respiratory depression, hypotension, loss of consciousness and cardiac arrest were developed about 20 minutes after the first injection of 1% lidocain 10ml. Endotracheal intubation was performed and the respiration was controlled using 100% oxygen. Self respiration and alert mentality returned after 180 minutes. No CSF leakage, delayed onset time, severe hypotension, complete recovery may be the result of subdural anesthesia and postoperative hypoxia. But radiological examination was not performed.

A Case of Suspicious Subdural Block During Epidural Anesthesia for Cesarean Section / 대한마취과학회지

Accidental subdural block is one of the rare complications of epidural anesthesia and can lead to a life threatening condition. A healthy 40 year old woman underwent cesarean section under the diagnosis of placenta previa. Single epidural puncture was performed at L3-4 interspace without difficulty. A test dose of 3ml of 1.5% lidocaine was injected without adverse effects. However, hypotension(80/40) and loss of pain sensation up to the level of C4 were devloped in 5 min. after injection of 25 ml of 1.5% lidocaine with 50ug fentanyl and 2.5ml of 8.4% sodium bicarbonate. She complained of dyspnea without change of SpO2 and difficulty of phonation about 15min. after injetion. And then, She was lethargic, but was able to open eyes with verbal communication. She was fully recovered in 180 minutes after epidural injection. Such extensive block might be caused by subdural administration of the drugs even if it was not confirmed radiologically.

Inadvertent subdural block in epidural anesthesia: A case confirmed by radiographic contrast material / 대한마취과학회지

Malposition of catheter in the subdural space is a possible complication during attempted epidural anesthesia. We report here an inadvertent subdural block confirmed by the radiographic contrast materiaL Epidural anesthesia was planned for a full-term gravida and epidural catheter was inserted about 3 cm cranially at the level of L1-2. After injection of 19.5 ml local anesthetic, blood pressure was 70/50 mmHg. Fluid was rapidly infused and intravenous ephedrine 10 mg was given. After then, vital signs were well maintained and twin babies were delivered without events. Twentyfive minutes later, she complained chest tightness and became tachypneic. Ketamine 50 mg was given and endotracheal intubation was performed with ease. She obeyed command, but could not open her eyes for some duration. Self respiration returned after 110 minutes and minute ventilation was 6 liter/minute at that time. 160 minutes later, extubation was done and radiological examination was performed using contrast materiaL The cathter tip was positioned in anterior subdural space at T12 level.

Inadvertent Subdural Block Confirmed by Subduragram / 대한마취과학회지

Accidental subdural extra-arachnoid block is a rare but life-threatening complication of epidural anesthesia. The subdural area is a potential space between the dura and the subarachnoid membranes. It exists in the spinal meninges just as it does in the cranial meninges. In the past 19 years a number of clinical reports have described the unintentional catheterization to this potential space and delayed subdural migration of the epidural catheter. We had three cases of accidental subdural blocks recently. Tbis is a report concerning a case confirmed by subduragram. A healthy 44 years old woman underwent a radical hysterectomy under continuous epidural anesthesia combined with general anesthesia. Epidural catheterization was carried out smoothly and the induction of general anesthesia was uneventful. However, an unexpected hypotension was continuously noticed after the epidural injection of 2% lidocaine 20 ml. Thereafter, general anesthetic was turned off and the respiration was controlled using 100% oxygen. The patient remained unconscious with severe miosis for one and a half hours. 5 ml of a water soluble Niopam 300 was injected through the catheter postoperatively. It was later observed on the subduragram that the catheter was inadvertently misplaced in the subdural space. The anatomy and physiological changes related to subdural block are described hereafter.

Inadvertent Subdural Block Developed by Epidural Anesthesia / 대한마취과학회지

Dural puncture in a well recognised complications of lumbar epidural anesthesia, as is extensive block after extradural injection of local anesthetic solutions in patients in whom the dura has been punctured. A healthy 43-year-old woman entered for trans-abdominal hysterectomy under lumbar epidural anesthesia. After an accidental dural puncture was noticed then the epidural puncture was reattempted at the same site and a catheter was inserted succesfully. An extensive segmental anesthesia along with hypotension and pupil dilatation developed about 45 minutes after the first injection of lidocain. Such extensive segmental anesthesia may be the result of injection into the subdural space. However, it was not confirmed in this case radiologically.