Thursday, May 26, 2005

Total spinal/high spinal

Just to share a scenario that i experienced not long ago.. Well, i have been working in the anaes department for five & half years already and have given or did thousands of cases of spinal anaesthesia, but so far i never encountered any cases of high spinal or total spinal yet till that day... which really give me a shock !!!

My patient was was 29 year old lady, G2P1 with Hx of LSCS done under SAB in Hosp Kota Bahru now came in post date in active labour. She refused trial of scar and was posted for emergency LSCS.

I preloaded her with 500 ml Ringer's Lactate prior to performing SAB.. given 2.0 ml heavy marcain at left lateral position at the level L3L4. I didn't check the height of block/ upper spinal level not tested pre-op after SAB.

The surgeon started skin incision and after a while, while i was preparing the oxytocin 40 units in the IV Drip, i noticed the pulse oxymeter alarming.. I turned my head to the monitor and noticed patient desaturating.. and SpO2 dropped very fast to 50% within seconds.... Patient actually became unconscious, unarousable to call, stopped breathing and cyanosed.. blue in colour.. I really have a high surge of adrenaline level at that moment...

I quickly manual ambu bagging the patient with 100% oxygen and intubated her fast with ETT 7.0 without any drugs. The lowest BP noted is around 85/40 and she didn't have any episodes of bradycardia. HR maintained around 80 to 95 bpm. The hypotension responded to iv ephedrine (total 24 mg ephedrine given) & fluid challenge with crystalloids. No fits/facial twitching noted.

Post intubation & after manual bagging with 100%, SpO2 picked up very fast. Pt regained consciousness in a short while & obey commands (no muscle relaxants given to her earlier on) She able to breath spontaneously and generating good tidal breath. Able to move left upper limbs but not the right side. The she became restless & wanted to pull out ETT. She was put on O2/N2O with flow 3:3 with inhalational agent & muscle relaxant tracium given. Baby delivered in a short while with apgar score 6 on delivery; attended immediately by paeds. Baby was alright after a while and send for observation in PBU.

Subsequently, her hemodynamic was fairly stable. Her BP was stable & didn’t require any inotropic support & no episodes of severe bradycardia. Blood loss minimal intra op. Total 1.5 L crystalloid given + 500 ml RL with 40 unit oxytocin in progress.

Pt was sent to ICU post op for observation & extubation. She was sedated (given iv midazolam 2 mg & iv morphine 4 mg) prior to sending to ICU. She arrived ICU one and half hours after the SAB. In GICU, the pt open eyes to call & obey simple commands, able to take deep breath., able to move both upper limbs.. The sensory level was around T10 when tested (1.5 hours post SAB). Pt able to move both her lower limbs within 2 hours. Pt was extubated well & observed in ICU for a while and transferred back to maternity HDA 3 hours later. She recovered well with no neurological sequelae.

9 comments:

Mr Burns said...

Confirm drunk

homer simpson said...

D'oh!

Chen said...

who on earth is this mr burn & homer simpson?

Mr Burns said...

Excellent!!!

homer simpson said...

Boriiinnnggg...

mmmm... beer...

principal skinner said...

who's drinking beer?

dr reb0rn said...

:O
suddenly got burns, simpson and skinner...

confused

Gasman said...

Well, i guess these burns, simpson and skinner got drunken and enter the site..
Anyway, got the same scenerio to share with you, my case was 34 Malay G5p4 as usual refused trial of scar posted for LSCS. The patient height is ok above 140cm (anyway, i have been giving spinal 2cc 0.5% Heavy Marcain to those LSCS with as short as 135cm, at level of L3-4, thank god nothing happen!) I usually push in the marcain slooooowly and then slight head up about 15 degree and tested the site of anesthesia. My case is i guess, local toxicity, she complaint of numbness over the upper limbs first with all the vital signs stable, BP maintain at 120 systolic and SPO2 at 100%, PR 90bpm to 110bpm. HM on the go, later she did c/o perioccular numbness. Op done with min blood loss and she was put in recovery for observation for one hour plus and discharge well with no neurological deficits. Thnk god.

Chen said...

gasman,

thanks for sharing..
My pt is 143 cm with body weight 72.5 kg.

In fact after sharing the case with my colleagues, i noticed few of them have similar experiences as well.. and patient was intubated intra op & manage to extubate uneventfully post op :)

But this is indeed a scary experience.. I really scared of any neurological sequelae or any hypoxic brain damage :) As u know, maternal mortality is indeed a big "huh-hah"