Accidental total spinal block (1)

R E P L Y Thank you for giving us the opportunity to respond to Dr. Fortuna's comments. It is possible that apnoea in this patient can partly be from hypotension and brainstem hypoperfusion, but she did develop flaccid paralysis in her upper extremities which means that motor paralysis in the cervical region had, indeed, taken place. The block, however (both sensory and motor), started regressing fairly quickly. The clincal picture developed with remarkable speed and consequences could have been disastrous. Understandably, therefore, we were occupied by measures at resuscitation and saving the baby. We are not, therefore, sure if the actual recovery o f the block coincided with the restoration o f blood pressure or it was "spontaneous." Measures were taken to avoid aorta-caval compression in the mother. She was placed in the leJ~ lateral recumbent position until the baby was delivered, t "Total Spinals" do occur accidentally aJ~er a massive epidural dose o f local anaesthetic gets into the subarachnoid space. Whether our case can or cannot be called a "total spinal" is o f academic interest only. The purpose o f our report was to emphasize the importance o f being watchful, to recognize and treat the consequences o f a neuraxial block (or a test dose) in a parturient as speedily as possible to prevent any longlasting deleterious effects on the mother or her infant. We chose to administer a general anaesthetic to our patient for the following reasons: (1) by the time she was being transferred to the OR, the block (both sensory and motor), was receding and since only 45 mg o f lidocaine had been used, we were not sure i f this would provide adequate analgesia for the surgery. (In our institution, the operating time for C-sections is about one hour.) (2) This patient exhibited an unusual response to 45 mg lidocaine. We, therefore, did not consider it appropriate, at this time, to try another dose or another local anaesthetic agent. (3) The foetus had developed foetal distress (FHR ~ 60 rain -~ with late decelerations) and the quickest way to deliver the baby is by administering a general anaesthetic. We thank Dr. Fortuna for showing interest in our case report. Neelkanth V. Palkar MD FFARCS Randall C. Boudreaux MD Aparna V. Mankad MD Department of Anesthesiology University of South Alabama Medical Center Mobile, AL 36617. USA