A 23-year-old woman at 38 weeks of gestation required an urgent cesarean section because of arrest of dilatation and non-reassuring fetal heart tracings. She had a history of poorly-controlled asthma and had been using an albuterol inhaler up to four times daily, but denied any recent asthma attack. Preoperative physical examination was unremarkable. In the operating suite, crystalloid preloading was started and spinal anesthesia was administered at the L3–4 interspace with bupivacaine 12 mg and morphine 200 μg. The patient was positioned supine with 15° left lateral tilt. Standard monitors were applied, non-invasive blood pressure (BP) readings were taken at 1-min intervals and supplemental oxygen was administered via nasal cannulae. The BP fell to 75/39 mmHg and after intravenous phenylephrine 120 μg increased to 91/63 mmHg. The patient vomited shortly thereafter and began complaining of difficulty breathing. She was reassured. The surgical team prepared the patient for cesarean section. Block density was assessed by pinprick and was considered adequate although the level was not precisely localized. Grip strength was maintained. On chest auscultation, bilateral wheezing was heard and so four puffs from an albuterol metered-dose inhaler (MDI) were administered. The patient was following commands, however her respiratory distress progressed. Assisted ventilation was attempted briefly as the patient lost consciousness but airway resistance was very high. The surgical team was asked to proceed. Apnea and declining oxygen saturation to 61% ensued with a BP of 140/71 mmHg and a heart rate of 72 beats/min. Rapid-sequence intubation was performed by the anesthesia resident following administration of propofol 150 mg and succinylcholine 100 mg. Despite an adequate laryngeal view, there was no end-tidal carbon dioxide tracing and no discernable air flow on auscultation following tracheal intubation. Additional succinylcholine 100 mg was given and the tracheal tube was exchanged by the attending anesthesiologist, but still no airflow was appreciated. The baby was delivered <3 min after incision with Apgar scores of 8 and 9 at 1 and 5 min, respectively.
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Published online: August 16, 2011
Accepted: June 14, 2011
© 2011 Elsevier Ltd. Published by Elsevier Inc. All rights reserved.