Can J Anesth/J Can Anesth (2014) 61:1004–1007
DOI 10.1007/s12630-014-0219-5
CASE REPORTS / CASE SERIES
Reversal of high spinal anesthesia with cerebrospinal lavage after
inadvertent intrathecal injection of local anesthetic
in an obstetric patient
Réversion d’une rachianesthésie haute par lavage
cérébro-rachidien après injection intrathécale accidentelle d’un
anesthésique local chez une patiente obstétricale
Heather Y. Z. Ting, MD • Ban C. H. Tsui, MD
Received: 15 May 2014 / Accepted: 4 August 2014 / Published online: 15 August 2014
! Canadian Anesthesiologists’ Society 2014
Abstract
Purpose High or total spinal anesthesia commonly
results from accidental placement of an epidural catheter
in the intrathecal space with subsequent injection of
excessive volumes of local anesthetic. Cerebrospinal
lavage has been shown to be effective at reversing the
effects of high/total spinal anesthesia but is rarely
considered in obstetric cases. Here, we describe the use
of cerebrospinal lavage to prevent potential complications
from high/total spinal anesthesia after unintentional
placement of an intrathecal catheter in a labouring
obstetric patient.
Clinical features A 34-yr-old female presented to the
labour and delivery unit in active labour. Epidural
anesthesia was initiated, and after the first bolus dose,
the patient experienced lower extremity motor block and
shortness of breath. A high spinal was confirmed, and
cerebrospinal lavage was performed. In total, 40 mL of
cerebrospinal fluid (CSF) were exchanged for an equal
volume of normal saline. The patient’s breathing
difficulties and motor block resolved quickly, and a new
epidural catheter was placed after removal of the spinal
catheter. Pain control was effective, and the patient
delivered a healthy baby.
Author contributions Heather Ting contributed to the acquisition
of data and Ban Tsui contributed to the original concept. Heather
Ting and Ban Tsui contributed to the analysis and interpretation of
data, drafting the article, and revising the article critically for
important intellectual content.
H. Y. Z. Ting, MD ! B. C. H. Tsui, MD (&)
Department of Anesthesiology and Pain Medicine, University of
Alberta, 8-120 Clinical Sciences Building, Edmonton,
AB T6G 2G3, Canada
e-mail: btsui@ualberta.ca
123
Conclusion We show that exchange of CSF for normal
saline can be used successfully to manage a high spinal in
an obstetric patient. Our results suggest that CSF lavage
could potentially be an important and helpful adjunct to the
conventional supportive management of obstetric patients
in the event of inadvertent high or total spinal anesthesia.
Résumé
Objectif Une rachianesthésie haute ou totale est
habituellement la conséquence du positionnement
accidentel d’un cathéter épidural dans l’espace intrathécal
suivi de l’injection de volumes excessifs d’anesthésique
local. Le lavage cérébro-rachidien a été démontré efficace
pour renverser les effets d’une rachianesthésie haute/
totale, mais cette option est rarement envisagée en
obstétrique. Nous décrivons ici l’utilisation d’un lavage
cérébro-rachidien pour la prévention de complications
potentielles résultant d’une rachianesthésie haute/totale
après le positionnement accidentel d’un cathéter intrathécal
chez une patiente obstétricale en travail.
Caractéristiques cliniques Une femme de 34 ans s’est
présentée en travail actif dans l’unité de travail et
d’accouchement. Une anesthésie péridurale a été débutée
et, après l’administration du premier bolus, la patiente a
présenté un bloc moteur des membres inférieurs et un
essoufflement. Une rachianesthésie haute a été confirmée et
un lavage cérébro-rachidien a été pratiqué. Au total,
40 mL de liquide céphalo-rachidien (LCR) ont été
remplacés par un volume égal de sérum physiologique.
Les difficultés respiratoires et le bloc moteur de la patiente
ont rapidement diminué et un nouveau cathéter épidural a
été mis en place après le retrait du cathéter rachidien. Le
contrôle de la douleur a été efficace et la patiente a
accouché d’un bébé en bonne santé.
Reversal of high spinal anesthesia
Conclusion Nous démontrons que le remplacement de
LCR par du sérum physiologique peut être utilisé avec
succès pour gérer une rachianesthésie haute chez une
patiente obstétricale. Nos résultats suggèrent que le lavage
du LCR peut constituer une technique d’appoint potentielle
et utile à la gestion conventionnelle de soutien chez des
patientes obstétricales subissant une rachianesthésie
accidentelle haute ou totale.
Background
High or total spinal anesthesia is uncommon, but it is one
of the most serious complications of epidural analgesia in
obstetric anesthesia practice.1 It can occur when excessive
local anesthetic is injected into the intrathecal space due to
unrecognized intrathecal or subdural placement of the
epidural catheter followed by subsequent migration of the
catheter into the intrathecal space. The typical clinical
presentation of high or total spinal anesthesia is intensive
lower limb motor block progressing to respiratory failure
and cardiovascular collapse. This devastating complication
often necessitates immediate intubation and cardiovascular
support, frequently followed by emergency Cesarean
delivery. The current case report describes the successful
reversal of spinal anesthesia with cerebrospinal lavage,
potentially preventing complications from high or total
spinal anesthesia after unintentional placement of an
intrathecal catheter in a labouring obstetric patient.
Case
The patient provided written consent to publish this case.
A 34-yr-old female, gravida 2 para 1, presented to the
labour and delivery unit in active labour. Her height and
weight were 165 cm and 77 kg, respectively. Her medical
history was unremarkable, and no problems were reported
for the current pregnancy. For her prior delivery, the
patient received epidural anesthesia and disclosed that the
‘‘learner’’ had a difficult time performing the epidural and
had to call on the attending anesthesiologist to complete
the procedure. The attending anesthesiologist inserted the
epidural without any problems. The epidural was effective,
and the patient had an uneventful delivery.
For the current delivery, epidural anesthesia was
initiated after obtaining consent from the patient. With
the patient in a sitting position, a midline approach at the
L3/4 interspinous space was used with a 17G Tuohy needle
with a plastic syringe to detect loss of resistance to air. At
the 7 cm mark, there was a loss of resistance. No blood or
cerebrospinal fluid (CSF) from the Tuohy needle was
1005
detected, and a 19G epidural catheter was inserted easily.
Following negative aspiration from the catheter, 2%
lidocaine 3 mL was administered as a test dose. A few
seconds after injection of the test dose, the patient
described a tingling sensation but no motor block in the
legs. At this time, the patient was able to move from a
sitting position at the side of the bed to a semi-Fowler’s
position by pivoting herself and swinging her legs back
onto the bed. The patient was able to flex both her knees,
confirming the absence of motor block. A blood pressure
reading of 140/70 mmHg was obtained, which was
followed by a first bolus injection through the catheter of
0.1% bupivacaine 5 mL with fentanyl 5 lg!mL-1
approximately five minutes after the initial test dose.
Within one minute of the first bolus dose, the patient
sensed that her legs were getting numb and heavy. Using
ice, we discovered that the patient’s block level was
ascending rapidly to T5, and she was also experiencing
shortness of breath with progressively laboured breathing
over time. A high spinal anesthesia was suspected and
subsequently confirmed when clear CSF was aspirated via
the epidural catheter. A crash cart was immediately
requested to prepare for potential intubation and
cardiovascular support. While this was being arranged,
the patient was placed in a high Fowler’s position (by
raising the head of the bed) and given 100% oxygen with a
non-rebreather mask. Following this, CSF lavage was
initiated: for every 10 mL of CSF removed, 10 mL of
normal saline were injected into the spinal catheter. In
total, 40 mL of CSF were aspirated from the spinal catheter
and replaced with an equal volume of normal saline.
Throughout the lavage procedure, the patient’s oxygen
saturation remained normal (98-100%), and the continuous
fetal heart rate monitor displayed a reassuring rate. The
patient’s blood pressure was also monitored closely, with
the lowest reading being 103/50 mmHg (baseline
140/70 mmHg). Three doses of ephedrine 5 mg were
given intravenously as a prophylactic measure to mitigate
worsening of cerebral and fetal perfusion due to any further
reduction in blood pressure. The patient’s breathing
difficulty quickly resolved, and her motor block receded
whereby she was able to move her legs completely within
five minutes.
After discussion with the patient, the spinal catheter was
removed, and a new epidural catheter was inserted without
any problems. The new epidural catheter was inserted
using the same approach as described above at the L2/3
interspinous space with loss of resistance to air at 5 cm at
the skin. Epidural analgesia was re-initiated for pain
control an hour later, and the patient delivered a healthy
baby four hours afterward. No postdural puncture headache
was reported on discharge or at the post-delivery follow-up
at three weeks.
123
1006
Discussion
This novel case describes the successful reversal of high
spinal anesthesia and prevention of potential progression to a
state requiring full cardiopulmonary support and emergency
Cesarean delivery. Although use of CSF lavage to manage
high and total spinal anesthesia is not a new concept, as we
and others have previously reported,2-6 it is rarely mentioned
as a possible consideration in management of complications
in obstetric regional anesthesia. In contrast, there are
numerous publications advocating CSF lavage as a viable
option for managing inadvertent intrathecal injection of
excessive opioid or chemotherapeutic agents resulting from
medication error.2,4,7,8
The incidence of inadvertent dural puncture during
epidural anesthesia in obstetrics has been quoted to be from
0.2-3%.9,10 Occasionally, there is no backflow of CSF
through the Tuohy needle or aspiration through the
epidural catheter to warn of an accidental dural
puncture;11 thus, routine use of a test dose is
recommended. Despite this, cases of high/total spinal
anesthesia following a test dose have been reported.12,13 In
our case, we waited for five minutes without any clinical
sign of intrathecal injection before injecting bupivacaine. It
is possible that a more thorough assessment of the patient
following the test dose as well as waiting for the effects of
the test dose to fully develop may have allowed us to detect
signs of covert intrathecal placement.
Although total spinal anesthesia is rarely seen in
nonobstetric patients, with a reported incidence of one in
16,000 patients,1 obstetric patients are at particularly
higher risk. This is due to enlargement of epidural
venous plexuses, which reduces spinal CSF volume and
increases the risk of cephalad spread of local anesthetic.
Indicators of high or early total spinal anesthesia include
heaviness in the lower limbs followed by numbness of the
hands and/or respiratory difficulty. Close monitoring with
pulse oximetry and delivery of adequate airflow must be
performed to maintain respiratory function.14 Total spinal
anesthesia is considered a genuine medical emergency as
it can cause profound hypotension, apnea, and
unconsciousness. As a result, invasive measures, such as
endotracheal intubation and mechanical ventilation, are
frequently required. In the case described here, we
immediately arranged and prepared for such an
intervention but decided to perform CSF lavage while
organizing such emergency measures.
Our use of CSF lavage was well tolerated by the patient,
and it facilitated rapid reversal of her high spinal
anesthesia. It also allowed our parturient to have a
normal vaginal delivery rather than potentially
progressing to a state where an emergency Cesarean
delivery under general anesthesia would be required. In our
123
H. Y. Z. Ting, B. C. H. Tsui
view, this simple maneuver may have avoided the high
maternal and neonatal risks and potential liability
associated with such a procedure.15
The differential diagnoses of the hypotension and
shortness of breath seen in this case included aortocaval
compression, amniotic fluid embolism, and anaphylaxis;
however, the rapid onset of motor and sensory block with
corresponding hypotension temporally related to the first
bolus of bupivacaine made high spinal anesthesia the
primary diagnosis. Given these symptoms in a labouring
obstetric patient and the limited time window for safe
delivery, we considered it more prudent to attempt to
reverse the effects of the spinal rather than to assume a
‘‘wait and see’’ approach.
Importantly, the potential risks and benefits of CSF
exchange should be considered prior to beginning the
procedure. When considering CSF lavage, both the type
and volume of solution should be selected carefully. Normal
saline,16 lactated Ringer’s solution,2 and Plasma-LyteTM17
(Baxter International Inc) have previously been used for CSF
lavage, and although perfusion of the cerebral ventricles has
been shown to cause side effects, such as headache and fever,
no other significant morbidity has been reported.16,17 In this
case, sterile, preservative-free normal saline (Na
154 mEq!L-1; osmolality, 308 mOsm!L-1; pH 5.5) was
chosen over other possible perfusates as it was readily
available, and we considered an expedited therapy to be
essential and critical in preventing further deterioration of
the patient’s hemodynamic and respiratory condition. For
non-emergency circumstances, Plasma-LyteTM (Na
140 mEq!L-1; osmolality, 294 mOsm!L-1; pH 7.4) has
been suggested as the preferred solution.17
In our patient, lavage of the spinal catheter with normal
saline clearly facilitated prompt reversal of high spinal
anesthesia. A possible explanation for this rapid action may
be that the volume of CSF in the lumbosacral area is
relatively small, facilitating quick exchange of local
anesthetic-contaminated CSF with normal saline.
Lumbosacral CSF volumes vary among individuals, but
mean volumes have been reported to be from 36-54 mL,18-20
while total CSF volume is approximately 150 mL. In
pregnant women, however, it is known that lumbar CSF
volume is reduced due to compression of the dural sac by the
engorged epidural veins, which accounts for the enhanced
spread of both spinal and epidural injectates in obstetric
patients.21 We speculated that removal of 40 mL of CSF (the
patient’s approximate total lumbosacral CSF volume)
allowed removal of a large portion of the local anesthetic.
In this case, four aliquots of 10 mL each were used for
convenience. Nevertheless, experience with epidural lavage
is limited, and the safe maximum volume and frequency of
exchanges of CSF with saline replacement remain a topic for
further study.
Reversal of high spinal anesthesia
The main benefit of cerebrospinal lavage is its utility to
dilute and/or remove a drug that has been inadvertently
injected into the intrathecal space, limiting the ability of the
drug to have neurological effects.22-24 While lipid emulsions
have been used to reverse the cardiotoxic effects following
inadvertent injection of local anesthetics into the
bloodstream,25-27 no known antidotes or agents exist to
treat excessive doses of local anesthetic for spinal anesthesia.
Thus, CSF lavage can be an effective method for mitigating
the effects of local anesthetics by diluting their concentration
in the intrathecal space or physically removing them in
exchange for a physiologically suitable solution.
In summary, this case report reminds us that CSF lavage
can be a useful maneuver in the event of high and/or total
spinal anesthesia following inadvertent intrathecal injection
of excessive local anesthetic. This case shows that CSF
withdrawal hastens recovery from an excessive spinal block
and prevents it from progressing to total spinal anesthesia. It
is therefore reasonable to consider the replacement of
30-40 mL of CSF with an equal volume of preservative-free
normal saline, lactated Ringer’s solution, or Plasma-Lyte
via the epidural catheter. Cerebrospinal fluid lavage could
potentially be an important and helpful adjunct to the
conventional supportive management of patients in the
event of an inadvertent high or total spinal anesthesia in
labouring obstetric patients.
Funding Dr. Tsui is supported by a Clinical Scholar Award from
the Alberta Heritage Foundation for Medical Research (AHFMR). Dr.
Tsui’s research is also supported by the Canadian Anesthesia
Research Foundation.
Conflict of interest None declared.
References
1. Jenkins JG. Some immediate serious complications of obstetric
epidural analgesia and anaesthesia: a prospective study of
145,550 epidurals. Int J Obstet Anesth 2005; 14: 37-42.
2. Al Ferayan A, Russell NA, Al Wohaibi M, Awada A, Scherman B.
Cerebrospinal fluid lavage in the treatment of inadvertent
intrathecal vincristine injection. Childs Nerv Syst 1999; 15: 87-9.
3. Covino BG, Marx GF, Finster M, Zsigmond EK. Prolonged
sensory/motor deficits following inadvertent spinal anesthesia.
Anesth Analg 1980; 59: 399-400.
4. Kaiser KG, Bainton CR. Treatment of intrathecal morphine
overdose by aspiration of cerebrospinal fluid. Anesth Analg 1987;
66: 475-7.
5. Southorn P, Vasdev GM, Chantigian RC, Lawson GM. Reducing
the potential morbidity of an unintentional spinal anaesthetic by
aspirating cerebrospinal fluid. Br J Anaesth 1996; 76: 467-9.
6. Tsui BC, Malherbe S, Koller J, Aronyk K. Reversal of an
unintentional spinal anesthetic by cerebrospinal lavage. Anesth
Analg 2004; 98: 434-6.
7. Boyer EW. Management of opioid analgesic overdose. N Engl J
Med 2012; 367: 146-55.
1007
8. Butala BP, Shah VR, Bhosale GP, Shah RB. Medication error:
subarachnoid injection of tranexamic acid. Indian J Anaesth
2012; 56: 168-70.
9. Introna RP, Blair JR, Neeld JB. What is the incidence of
inadvertent dural puncture during epidural anesthesia in
obstetrics? Anesthesiology 2012; 117: 686-7.
10. Turnbull DK, Shepherd DB. Post-dural puncture headache:
pathogenesis, prevention and treatment. Br J Anaesth 2003; 91:
718-29.
11. Abraham RA, Harris AP, Maxwell LG, Kaplow S. The efficacy of
1.5% lidocaine with 7.5% dextrose and epinephrine as an epidural
test dose for obstetrics. Anesthesiology 1986; 64: 116-9.
12. Richardson MG, Lee AC, Wissler RN. High spinal anesthesia after
epidural test dose administration in five obstetric patients. Reg
Anesth 1996; 21: 119-23.
13. Steffek M, Owczuk R, Szlyk-Augustyn M, Lasinska-Kowara M,
Wujtewicz M. Total spinal anaesthesia as a complication of local
anaesthetic test-dose administration through an epidural catheter.
Acta Anaesthesiol Scand 2004; 48: 1211-3.
14. Ben-David B, Rawa R. Complications of neuraxial blockade.
Anesthesiol Clin North America 2002; 20: 669-93.
15. Davies JM, Posner KL, Lee LA, Cheney FW, Domino KB.
Liability associated with obstetric anesthesia: a closed claims
analysis. Anesthesiology 2009; 110: 131-9.
16. Oka K, Yamamoto M, Nonaka T, Tomonaga M. The significance
of artificial cerebrospinal fluid as perfusate and
endoneurosurgery. Neurosurgery 1996; 38: 733-6.
17. Bergsneider M. Endoscopic removal of cysticercal cysts within
the fourth ventricle. Technical note. J Neurosurg 1999; 91: 340-5.
18. Carpenter RL, Hogan QH, Liu SS, Crane B, Moore J.
Lumbosacral cerebrospinal fluid volume is the primary
determinant of sensory block extent and duration during spinal
anesthesia. Anesthesiology 1998; 89: 24-9.
19. Hogan QH, Prost R, Kulier A, Taylor ML, Liu S, Mark L.
Magnetic resonance imaging of cerebrospinal fluid volume and
the influence of body habitus and abdominal pressure.
Anesthesiology 1996; 84: 1341-9.
20. Sullivan JT, Grouper S, Walker MT, Parrish TB, McCarthy RJ,
Wong CA. Lumbosacral cerebrospinal fluid volume in humans
using three-dimensional magnetic resonance imaging. Anesth
Analg 2006; 103: 1306-10.
21. Onuki E, Higuchi H, Takagi S, et al. Gestation-related reduction
in lumbar cerebrospinal fluid volume and dural sac surface area.
Anesth Analg 2010; 110: 148-53.
22. Lee DS, Bui T, Ferrarese J, Richardson PK. Cauda equina
syndrome after incidental total spinal anesthesia with 2%
lidocaine. J Clin Anesth 1998; 10: 66-9.
23. Ravindran RS, Bond VK, Tasch MD, Gupta CD, Luerssen TG.
Prolonged neural blockade following regional analgesia with
2-chloroprocaine. Anesth Analg 1980; 59: 447-51.
24. Rose JB. Spinal cord injury in a child after single-shot epidural
anesthesia. Anesth Analg 2003; 96: 3-6.
25. Litz RJ, Popp M, Stehr SN, Koch T. Successful resuscitation of a
patient with ropivacaine-induced asystole after axillary plexus
block using lipid infusion. Anaesthesia 2006; 61: 800-1.
26. McCutchen T, Gerancher JC. Early intralipid therapy may have
prevented bupivacaine-associated cardiac arrest. Reg Anesth Pain
Med 2008; 33: 178-80.
27. Rosenblatt MA, Abel M, Fischer GW, Itzkovich CJ, Eisenkraft JB.
Successful use of a 20% lipid emulsion to resuscitate a patient after
a presumed bupivacaine-related cardiac arrest. Anesthesiology
2006; 105: 217-8.
123