- Joined
- Oct 11, 2003
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20-something F presents in premature labor at 30 wks. Tocolysis started and steroids completed. Unreassuring fetal rhythm so off to CS.
Not obese. Good palpation of spinous process. Standard spinal kit with 25G needle. 1.6 cc of 0.75% Bupivacaine with 200 mcg Duramorph in syringe. I always get air out. 2x attempt with 25G no go with continued hitting bone. I believe I checked for CSF twice after pop but no return. Repositioning doesn't help. 1x attempt with 24G and in. Good CSF. T4 level. Never used LOR approach. Pt very hypotensive but Ephedrine helps. Pt c/o neck pain. CS complete and pt with return of LE strength 5/5 checked 3 hrs later.
12-24 hrs later pt with c/o severe HA. Colleague evaluates pt and not typical PDPH. Blood patch performed anyway without improvement of symptoms. OB orders CT, which notes moderate air in ventricles and air in subQ of posterior scalp and neck. Noted pituitary enlargement as well.
I placed pt of O2 for reabsoption. Feeling better. Never detected focal neuro deficit.
I know pneumocephalus is rare and is seen mostly with epidurals and use of LOR. I cannot figure out how all that air entered the CSF, never mind subQ.
I'm approaching 3 years in PP and 20% of my case load is OB. Perplexed and troubled by this case.
Any ideas?
Thank you.
Not obese. Good palpation of spinous process. Standard spinal kit with 25G needle. 1.6 cc of 0.75% Bupivacaine with 200 mcg Duramorph in syringe. I always get air out. 2x attempt with 25G no go with continued hitting bone. I believe I checked for CSF twice after pop but no return. Repositioning doesn't help. 1x attempt with 24G and in. Good CSF. T4 level. Never used LOR approach. Pt very hypotensive but Ephedrine helps. Pt c/o neck pain. CS complete and pt with return of LE strength 5/5 checked 3 hrs later.
12-24 hrs later pt with c/o severe HA. Colleague evaluates pt and not typical PDPH. Blood patch performed anyway without improvement of symptoms. OB orders CT, which notes moderate air in ventricles and air in subQ of posterior scalp and neck. Noted pituitary enlargement as well.
I placed pt of O2 for reabsoption. Feeling better. Never detected focal neuro deficit.
I know pneumocephalus is rare and is seen mostly with epidurals and use of LOR. I cannot figure out how all that air entered the CSF, never mind subQ.
I'm approaching 3 years in PP and 20% of my case load is OB. Perplexed and troubled by this case.
Any ideas?
Thank you.