Bupivacaine
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Convulsion and hypotension: case report A 38-year-old pregnant woman developed convulsion and hypotension following procedural administration of bupivacaine for spinal anaesthesia. The woman was scheduled for caesarean delivery at 37 + 1 weeks of gestation. She was diagnosed with pregnancy-induced hypertension, and she had been receiving aspirin to prevent preeclampsia. However, her BP was not well-controlled. Hence, it was decided to perform caesarean section 2 weeks before the scheduled date. Prior to the surgery, her laboratory tests and chest radiography were normal. Her ECG showed sinus tachycardia. In the operation room, her initial BP was 140/80mm Hg, HR was 122 beats/minute and peripheral oxygen saturation was 99%. Prior to the induction of anaesthesia, she had shallow and rapid breaths, and she was anxious. No anxiolytics were administered, only verbal comments were provided. Spinal anaesthesia was administered in the left lateral position in the third and fourth lumbar intervertebral space via 25 gauge needle. After achieving a free flow of CSF, hyperbaric bupivacaine 11mg was administered intrathecally for spinal anaesthesia. Thereafter, she was placed in the supine position, and sensory blockade was assessed. During assessment, she developed sudden onset convulsions in the bilateral upper extremities and face for 5 seconds. She also showed a slight decrease in mental status. Haemodynamic monitoring revealed BP 55/31mm Hg, HR 140 beats/minute oxygen saturation 99% (at 2 L/minute of oxygen). The woman was immediately treated with Ringer’s lactate [Hartmann’s solution] and phenylephrine. She had end-tidal carbon dioxide concentration of 17mm Hg. After 1 minute phenylephrine was administered for the second time. Two minutes after the second administration, BP was 40/25 mm Hg and HR was 130 beats/minute. Thereafter arterial catheterisation was performed to monitor BP, and phenylephrine was again administered. Arterial blood gas analysis showed acute respiratory alkalosis. Investigations revealed pH 7.543, partial pressure of arterial carbon dioxide (PaCO2) 25.4mm Hg, partial pressure of arterial oxygen (PaO2) of 184.5mm Hg and bicarbonate concentration (HCO3) 43.1 mEq/L. Her arterial BP was 100/74mm Hg with HR of 110 bpm and peripheral oxygen saturation was 100%. She recovered completely and was noted to be completely alert. After stabilisation of her haemodynamic status, sensory blockade was achieved, following which the surgery was started. Within 4 minutes, she delivered a healthy female neonate weighing 3350g. Apgar score was 7 and 9 at 1 minute and 5 minutes, respectively. Maternal arterial blood gas analysis revealed compensated respiratory alkalosis. Investigations revealed pH 7.414, PaCO2 26.4mm Hg, PaO2 of 207.7mm Hg, HCO3 16.5 mEq/L, base excess of -6.6 mEq/L and blood glucose level 97 mg/dL. The nasal prongs were replaced with a partial re-breathing mask. Twenty minutes later, arterial blood gas analysis revealed pH 7.425, PaCO2 of 25.2mm Hg, PaO2 of 257.2mm Hg, HCO3 of 16.2 mEq/L and base e
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