The use of spinal anesthesia in obstetrics is justified by the advantages it has over general anesthesia. It is a simple and easy technique. However, the possibility of serious complications or even death with this technique during cesareans leads to questions about its place [1].

In this work we will report a case of totalization of spinal anesthesia during a cesarean section, and describe its management.        

Observation

we report the case of a young patient aged 28, diabetic on insulin, with 2 previous pregnancies without particularity. admitted to our facility during her third full-term pregnancy for caesarean section, indicated because of macrosomia.

The parturient had a pre-anaesthetic evaluation; then installed in the operating room, the cardioscope indicated a heart rate at 88 beats per minute, blood pressure at 123/56 mmHg, pulsed oxygen saturation at 99% and respiratory rate at 13 cycles per minute. The blood sugar was at 1.04 g/dl and the temperature 37.2 degrees.

A spinal anesthesia wad decided, at the L2-L3 level in a seated position, using 10 mg of hyperbaric marcaine with 100 gammas of morphine and 25 gammas of fentanyl. After 13 minutes, the patient showed a loss of sensitivity of the 2 upper limbs with desaturation, agitation and tachycardia.

The patient was stabilized using epinephrine and mechanic ventilation. At the end of the surgery, we note that the condition of the newborn was unremarkable with an APGAR of 10/10.

An evaluation of the glycemia and the neurological state showed no awakening sign even after using sugamadex for decurarization. A cerebral CT scan was realized, with no particularity, so we had waited for 2 hours wainting the end of the marcaine effect. 

Once the patient has regained her respiratory autonomy and a spontaneous motricity of the 4 limbs, the extubation was realized and she was transfered to the intensive care unit for monitoring.

Spinal anesthesia is an anesthetic technique dating back to the end of the 19th century. It aims to inject a solution of a local anesthetic within the subarachnoid space after crossing, using a special needle, the ligamentous structures of  the  lumbar spine next to the L3-L4 or L4 floor. -L5 [2].

The use of spinal anesthesia in obstetrics is justified by the advantages it has over general anesthesia: preservation of consciousness and vigilance, which limits the risk of inhalation of gastric contents in these patients at risk; the quantity of local anesthetic administered is quite low, thus reducing the risk of toxic accident in the mother and/or the fetus [1].

The occurrence of total spinal anesthesia can be potentially catastrophic for both mother and baby [3]. This is a rare complication, which follows the introduction of local anesthetics into the subarachnoid space. It has been reported in attempted interscalene, epidural, and spinal block, but the mechanism of production remains obscure [4-6]. Total spinal anesthesia can occur at any time during childbirth after spinal anesthesia for caesarean section or placement of an epidural catheter for vaginal delivery. It is important to distinguish between total spinal anesthesia and high spinal block [3].

• High spinal or regional block corresponds to local anesthetic spread above T4. Effects vary in severity depending on the maximum level reached, and may include cardiovascular and/or respiratory disturbances

• Total spinal anesthesia corresponds to the intracranial diffusion of the local anesthetic resulting in loss of consciousness. The incidence reported in the literature is less than 1/100,000 cases

Without treatment, a high regional block can progress to total spinal anesthesia. The clinical characteristics depend on the level affected by the extension [3]:

• At T1-T4 level, the cardiac sympathetic fibers are blocked and there will be hypotension with bradycardia

• At C6-C8, there will be paresthesia or numbness of the hands/arms with shortness of breath (accessory respiratory muscles affected)

• At height of C3-C5: damage to the diaphragm and shoulders, which includes breathing

• In the event of intracranial spread: damage to the brainstem will cause slurred speech and loss of consciousness

Certain situations are particularly at risk, and should suggest control and management of the level of extension of local anesthetics, so we are talking about a rostral transfer. This is done by reducing the dose in the elderly, [7] and in situations where the intra-abdominal pressure is high (pregnancy, obesity, ascites) [8].

The addition of morphine does not modify the pharmacokinetics of AL. Sufentanil, fat- The management of total spinal anesthesia involves stopping the epidural pump if present, providing high flow oxygen via a face mask, if possible, placing the head of the bed upwards (reverse Trendelenburg) to avoid the diffusion of local anesthetic. Otherwise, left lateral position or supine position with manual uterine displacement [3]. If there is significant respiratory impairment or loss of consciousness and/or the airway, the patient will need intubation and ventilation: Induction will therefore be done in rapid sequence with cricoid pressure. Induction agents should always be used in reduced doses. Vasopressors must be ready to use. Sedation and ventilation should continue until the block resolves and spontaneous breathing resumes. This may take a few hours depending on the dose of local anesthetic used.

Once the mother is stabilized, an assessment of the fetus is required and the pediatric team should be called in to assist. Stabilization of the mother is therefore fundamental both for her and for the fetus [3].

Prevention during spinal anesthesia must take into account the level and dose of local anesthetic required for the surgery; the position of the patient and the height of the block, especially when using hyperbaric ("heavy") anesthetics; patient characteristics (consider dose reduction in obese patients); of the technique, namely the speed of injection [3]. It should be noted that total spinal anesthesia is an accident that remains rare, and whose prognosis is good when, as in the cases that have been reported, practitioners easily use vasopressors and artificial ventilation [9].

Total spinal anesthesia is an accident that remains rare, which can occur following spinal anesthesia or an epidural, and whose prognosis is good when practitioners use vasopressors and artificial ventilation early on. The medical team, namely doctors and nurse anesthetists, as well as midwives must maintain close monitoring of all parturient under spinal anesthesia or having benefited from an epidural catheter in order to avoid missing out on this complication, which is certainly formidable but reversible.

1. Carpentier, J.P. et al. “Practice and complications of spinal anesthesia in a tropical African environment.” Annales Françaises d’Anesthésie et de Réanimation, vol. 20, 2000, pp. 16–22.

2. Bier, A. “Versuche über Cocainisirung des Rückenmarkes (Experiments on the Cocainization of the Spinal Cord).” Deutsche Zeitschrift für Chirurgie, vol. 51, 1899, pp. 361–369.

3. Hermanowski, Jane and Aditi Modi. High Regional Block (Including Total Spinal Anesthesia). Women and Children’s and Clinical Support Services Division, Clinical Guideline MAT0054, Version 3, April 2017.

4. Ross, S. and C.D. Scarborough. “Total Spinal Anesthesia Following Brachial Plexus Block.” Anesthesiology, vol. 39, 1973, pp. 458–460.

5. DeSarram, M. “Accidental total spinal analgesia.” Anaesthesia, vol. 11, 1956, pp. 77–79.

6. Gupta, A. et al. “Spinal anaesthesia for caesarean section following epidural analgesia in labour: A relative contraindication.” International Journal of Obstetric Anesthesia, vol. 3, 1994, pp. 153–156.

7. Cohendy, R. et al. “Anaesthesia in the older patient.” Current Opinion in Clinical Nutrition and Metabolic Care, vol. 8, 2005, pp. 17–21.

8. Van Zundert, A.A. et al. “Spinal anesthesia: Volume or concentration, what matters?” Regional Anesthesia, vol. 21, 1996, pp. 112–118.

9. Citerne, A. and Y. Auroy. “About a perimedullary ALR accident.” Proceedings of the 53rd National Congress of Anesthesia and Resuscitation (SFAR), 2011.