Bupivacaine

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Total spinal anaesthesia: case report A 30-year-old woman developed total spinal anaesthesia following treatment with bupivacaine for epidural analgesia during pregnancy. The woman (gravida 2, para 1) presented at 39 weeks of gestation in labour with cervical dilatation. Her previous delivery had been performed by emergency cesarean section under epidural anaesthesia. Her medical history was significant for mild asthma which was being currently managed with inhaled beclometasone [beclomethasone] twice daily [dose not stated]. Upon current presentation, cesarean section was scheduled. She was hospitalised. Shortly after admission, epidural analgesia was requested. An 18 gauge Tuohy needle was inserted at the L3/4 interspace in the sitting position. The epidural space was located at 6cm via loss-of resistance to sodium chloride [saline] [dosage and indication not stated], and a closed-end epidural catheter with three lateral eyes was placed (5cm inserted into the space). Aspiration of the catheter was negative. Therefore, 0.25% bupivacaine 5mL (12.5mg) was administered as a test dose. Within 20 minutes after insertion, a total of 15mL of 0.25% bupivacaine (37.5 mg) had been administered in 5mL increments. However, she remained distressed by contractions. A further 5mL (12.5mg) of 0.25% bupivacaine was administered following a negative aspiration test. Fifteen minutes after this fourth dose, she reported that she was unable to breath. Chest auscultation was noted to be clear. Grip strength was intact. However, there was bilateral sensory loss to ice to C5. Motor block then rapidly progressed. She experienced anxiety. She was only able to speak in whispers and was unable to lift her head against gravity. Sensory block progressed to C2. Catheter aspiration showed clear fluid with a glucose concentration of 5.7 mmol/l. She was diagnosed with total spinal anaesthesia secondary to epidural anaesthesia with bupivacaine. A Bi-level Positive Airway Pressure (BiPAP) mask/machine was applied which revealed tidal volumes of 50-60mL prior to application of positive pressure. BiPAP was initiated with inspiratory positive airway pressure 6cm H2O, expiratory positive airway pressure 4cm H2O and inspired oxygen concentration (FiO2) of 100%. All breaths were patient-triggered, producing tidal volumes of 600 to 700mL at a respiratory rate of 18. Oxygen saturation (SaO2) was 100% throughout and the BiPAP was well tolerated. The woman appeared less anxious and dyspnoeic. Motor function gradually returned. BiPAP was removed after 40 minutes. A further 50 minutes later, the motor block resolved completely. However, there was residual sensory block to C7. Subsequently, she was transferred for caesarean section. Catheter aspiration still showed cerebrospinal fluid and the sensory block remained at C7 despite normal lower limb motor function. She was administered total of 1.5 mL of 0.5% bupivacaine [hyperbaric bupivacaine] (7.5mg) and fentanyl 15µg via the intrathecal catheter, which provided adequate intraoperative anaesthesia. She deli