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An Epidural Blood Patch Causing Acute Neurological Dysfunction Necessitating a Decompressive Laminectomy

anesthesia was provided with lidocaine and epinephrine. Initially, a T6 sensory level was obtained but additional local anesthetic was administered to achieve a T2 sensory level after she complained of intraoperative pain. She had noninvasive assistance with BiPAP during the surgery due to respiratory compromise. Midazolam 2mg was given after delivery of a healthy 2.2 kg boy with Apgar scores of 9 at 1 and 5 minutes. The second patient was a 36-year-old nulliparous woman with an FEV1 of 0.85L (32% predicted). Continuous oxygen therapy was started at 17 weeks and she remained in the hospital from 24 weeks due to infective exacerbations. She was delivered at 32 weeks. Combined spinal-epidural anesthesia was provided using 0.5% hyperbaric bupivacaine administered intrathecally (1.8mL) followed by 10mL of epidural 2% lidocaine with 1:200,000 epinephrine to reach a T6 block. IV ketamine and fentanyl were given for inadequate analgesia after delivery of a healthy 1.49 kg girl, with Apgar scores of 7 and 9 at 1 and 5 minutes. A phenylephrine infusion was used to maintain intraoperative hemodynamic stability. In the third case, a 39-year-old nulliparous patient had an FEV1 of 1.05L (36% predicted). She required lifelong anticoagulation because of peripherally inserted central catheter–related thromboses in both the arms. At 24 weeks’ gestation, she required nasogastric nocturnal feeding due to lack of weight gain. At 37 weeks, she delivered a healthy 2.7 kg girl with Apgar scores of 9 and 1 and 5 minutes. Anesthesia for CD was provided though spinal and epidural catheters. Initially, a sensory block to T6 was achieved with 0.5% hyperbaric bupivacaine (3mL) administered through the spinal catheter. When she complained of pain during surgery, she received 2% lidocaine with epinephrine via the epidural catheter. She was hemodynamically stable without the use of vasopressors throughout the CD. The final patient was a 20-year-old nulliparous woman, whose FEV1 was 1.06L (36% predicted). She had frequent infective exacerbations of her CF and deteriorating lung function that required hospitalization from 28 weeks. She underwent a planned CD at 34 weeks using combined spinal-epidural anesthesia with 0.5% hyperbaric bupivacaine (1.8mL) injected intrathecally along with epidural 2% lidocaine with epinephrine (5mL) given to achieve a T6 block. Anesthesia was adequate and a healthy 2.08 kg girl with Apgar scores of 7 and 9 at 1 and 5 minutes was delivered. Intraoperative hemodynamic stability was achieved using phenylephrine boluses for a total dose of 300 mg. All patients received 5U IV oxytocin over 5 minutes after delivery, followed by an infusion of 40U in 0.9% saline (500mL) at 62.5mL/h. Estimated blood loss in all cases was <400mL. Postoperative care for all these CF patients was aimed at minimizing the occurrence of respiratory tract infections. They were all managed in the ICU for the first 48 hours and then spent 7 to 19 days in the CF unit. Chest physiotherapy and routine nebulized drugs were resumed as quickly as possible after CD. Dieticians oversaw postoperative nutrition and weight management. Levobupivacaine and fentanyl were used for postoperative analgesia. Other postoperative measures included glycemic control with insulin, antiembolism stockings, and subcutaneous enoxaparin for thromboprophylaxis, and IV pantoprazole for stress ulcer prophylaxis. No infant was subsequently diagnosed with CF. The first and second patients died at 18 and 21 months, respectively, after delivery from complications associated with CF; cases 3 and 4 were alive at 8 and 3 months after delivery.