Total Spinal Anesthesia following Epidural Block for Correction with Ilizarov Apparatus in an Achondroplasia Patient: A case report / 대한통증학회지

Epidural analgesia using an epidural catheter is an effective method to relieve the pain during the rehabilitating procedure for postoperative orthopedic patients. Total spinal anesthesia is one of the possible complications of epidural catheterization which can lead to a life-threatening condition. Achondroplasia is the most common form of short-limbed dwarfism resulting from a failure of endochondral bone formation. In patients suffering with short stature syndrome like achondroplasia, the incidence and risk of total spinal anesthesia during epidural anesthesia may increase because of the technical difficulty and structural anomaly of the spine. We report here on a 35-year old female patient with a height of a 115 cm. She was diagnosed as achondroplasia and she had a previous Ilizarov operation; both tibial lengthening and correction of valgus were done. No specific event occurred during epidural catheterization. Immediately after the injection of a test dose via epidural catheter, the patient became hypotensive, drowsy and showed weakness of both her upper and lower extremities. The symptoms were disappeared after 40 minutes. The catheter was removed on the next day. We concluded that the total spinal anesthesia was caused by intrathecal injection of local anesthetics through the epidural catheter, and the anesthesia then migrated into the subarachonoid space.

Assessment of Autonomic Response before and after Total Spinal Anesthesia in Rats: Power Spectral Analysis / 대한마취과학회지

BACKGROUND: Total spinal anesthesia (TSA) after injections of local anesthetics into the intrathecal space during epidural anesthesia is not rare. TSA anesthetizes cranial nerves and peripheral nerves, causes specific circulatory disturbances related to autonomic imbalance. Spectral analysis of heart rate variability (HRV) and blood pressure variability (BPV) provide a dynamic assessment of sympathetic and parasympathetic tone. Cross-spectral analysis has been used to emphasize this dynamic baroreflex control of HR as a frequency-dependent phenomenon and allows an assessment of baroreflex function. To examine the effects of TSA on the autonomic nervous system, we used spectral and cross-spectral analytic METHODS. METHODS: We investigated 14 rats before and after TSA. Power spectral densities of blood pressure (BP) and heart rate (HR) were estimated by fast Fourier transform. To evaluate the effect of TSA on baroreflex function, the cross spectral gain, phase, and coherence between beat-to-beat BP and HR signals were calculated by using transfer function analysis. RESULTS: With the onset of TSA, BP and HR significantly decreased. TSA significantly decreased the low frequency (LF) and high frequency (HF) components of HRV and BPV. Baroreflex sensitivity (BRS) obtained from transfer function gain between these variables was significantly decreased. CONCLUSIONS: TSA reduces the LF and HF components of HRV and BPV. These suggest that TSA in rats decreases both parasympathetic and sympathetic drive. Moreover, the decrease in BRS suggests impairment of cardiac baroreflex buffering function during TSA.

Power Spectral Analysis of Heart Rate Variability during Total Spinal Anesthesia in Rats / 대한마취과학회지

BACKGROUND: Total spinal anesthesia (TSA) anesthetizes cranial nerves as well as peripherial nerves, leading to specific circulatory perturbations related to autonomic imbalance between sympathetic and parasympathetic tone. Heart rate variability (HRV) result from moment-to-moment changes in sympathetic and parasympathetic activity in response to many conditions. Using a power spectral analysis of heart rate variability, we evaluated the effect of TSA on the changes in the autonomic nervous system. METHODS: Twenty-four Sprague-Dawley rats, during halothane anesthesia, were placed in a stereotaxic head holder. Polyethylene tubing (PE-10) was passed caudally from the cisterna magna, and these rats were anesthetized by a urethane intraperitoneal injection (1.5 g/kg). Succinylcholine was infused intravenously at 1 mg/kg/min. During mechanical ventilation, ECG signals and mean arterial blood pressure were recorded for 5 min after a period of 10 min of anesthetic stabilization (baseline). Lidocaine (40 mg/kg) was administered intrathecally and then two subsequent 5-min ECG signals and mean arterial blood pressure were recorded (TSA 0 5 min, 5 10 min). A power spectral analysis of the data was computed using a short-time Fourier transform. The spectral peaks within each measurement were calculated; low frequency area (0.25 0.75 Hz), high frequency area (0.75 3.0 Hz), total frequency area (0.25 3.0 Hz). RESULTS: Mean R-R interval increases progressively during the 5 minutes after TSA but mean blood pressure decreases to the level of blood pressure of TSA within 2 minutes after TSA (p < 0.05). TSA diminished HRV within 2 minutes after a spinal injection of lidocaine (p < 0.05). CONCLUSIONS: These results suggest that total spinal anesthesia depresses both sympathetic and parasympathetic tone within 2 minutes.

Total Spinal Anesthesia as a Complication of Epidural Nerve Block: A case report / 대한마취과학회지

Epidural nerve block is the most widely practiced procedure in the pain clinic. Accidental dural puncture during epidural nerve block also has been associated with postdural puncture headache and total spinal anesthesia. Especially, total spinal anesthesia is the most serious complication of epidural nerve block and can lead to a life threatening conditions. We have experienced two cases in whom total spinal anesthesia occurred during epidural nerve block for neck and lower back pain control. Immediately after epidural nerve block, the patients became unresponsive and apneic with loss of muscle tone in all extremity. We performed resuscitations and about 3 hours later the patients recovered completely without any complication.

An Accidental Intrathecal Morphine Administration Associated with Total Spinal Anesthesia / 대한마취과학회지

The epidural injection on morphine is an effective method for postoperative pain management. The associated side effects have, however, precluded its widespread use in a variety of clinical settings. Intrathecal administration of morphine incurs a high incidence of pruritus, nausea and vomiting, somnolence, urinary retention and life-threatening respiratory depression in severe cases. We report here one case of accidental total spinal anesthesia with lidocaine, followed by intrathecal injection of morphine. A 39-year-old female with an ovarian tumor was scheduled for a total abdominal hysterectomy under epidural anesthesia. After the epidural space was identified erroneously, 20 ml of 2% lidocaine mixed with 1:200,000 epinephrine was administered into the epidural space, immediately followed by injection of morphine 3 mg. All signs of a total spinal block were observed. She was then intubated and her respiration was controlled without delay. The schedulled operation was carried out uneventfully for 1 hour and 20 minutes. In the recovery room, a bolus injection of naloxone 0.4 mg was performed for prevention of respiratory depression. Dripping of naloxone 0.4 mg/100 ml/hour was continued for 20 hours postoperatively. However, her respiratory rate started to be decreased to 9/min around 8 hours after the surgery so that naloxone 0.2 mg was again injected intravenously. Headache and other side effects were not observed. The patient was out of ICU and discharged on the 6th postoperative day.