title: Suspected total spinal in patient having emergent Caesarean section, a case report and literature review.
abstract: BACKGROUND
  Epidural analgesia is commonly used for management of pain during childbirth. Need for emergent Caesarean section e.g. because of signs of foetal distress or lack of progress is however not an uncommon event. In females having an established epidural; general anaesthesia, top-up of the epidural or putting a spinal are all possible options. Dosing of the spinal anaesthesia in females having epidural is a matter of discussion.
  
  
  METHODS
  We describe a healthy 32 years, 0 para mother in gestation week 36 having labour epidural analgesia but due to foetal distress scheduled for an emergent Caesarean section category 2 that developed upper extremity weakness and respiratory depression after administration of standard dose high density bupivacaine/morphine/fentanyl intrathecal anaesthesia. She was emergent intubated and resumed motor function after 15-20min.
  
  
  CONCLUSIONS
  A too extensive cephalic spread was the most plausible explanation to the event. Whether or not reducing the dose for a spinal anaesthesia in mothers having an established labour epidural analgesia is a matter of discussion. It is of course of importance to achieve a rapid and effective surgical anaesthesia but also avoiding overdosing with the risk for a too high cephalic spread.
  To perform spinal anaesthesia for emergent Caesarean in patients having an epidural for labour pain is a feasible option and should be considered in category 2-3 section. The dose for a convert spinal block should be assessed on an individual basis and reasonably reduced.
authors.affiliation: Department of Anaesthesia & Intensive CareInstitution for Clinical Science, Karolinska Institutet, Danderyds University Hospital, SE 182 88 Stockholm, Sweden. Electronic address: helena.virgin@ds.se.
authors.forename: H
authors.initials: H
authors.lastname: Virgin
authors.affiliation: Department of Anaesthesia & Intensive CareInstitution for Clinical Science, Karolinska Institutet, Danderyds University Hospital, SE 182 88 Stockholm, Sweden. Electronic address: eva.oddby-muhrbeck@ds.se.
authors.forename: E
authors.initials: E
authors.lastname: Oddby
authors.affiliation: Department of Anaesthesia & Intensive CareInstitution for Clinical Science, Karolinska Institutet, Danderyds University Hospital, SE 182 88 Stockholm, Sweden. Electronic address: jan.jakobsson@ki.se.
authors.forename: J G
authors.initials: JG
authors.lastname: Jakobsson
keywords: Caesarean section; Epidural analgesia; Spinal anaesthesia; Total spinal