br. j. anaesth. 1994 harding 545 7

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British Journal  o Anaesthesia  1994;  73 :  545-547 CASE REPORTS Meningitis after combined spinal-extradural anaesthesia in obstetrics S. A.  HARDING,  R. E.  COLLIS AND  B. M.  MORGAN Summary We report two cases  o f  meningitis which developed after combined spinal-extradural procedures  fo r obstetric analgesia. The first case was thoug ht  to be caused  by  aseptic  o r  chemical meningitis  an d  the second  was a  case  o f  bacterial meningitis  in a patient  who  also received  an  extradural blood patch.  It is  important that meningitis  is  considered as  a  differential diagnosis  in  patients  who  present with headache after spinal anaesthesia  and  that antibiotic therapy  i s  selected  to  cover unusual organisms.  Br .  J.  Anaesth 1994;  7 :  545-547 ey words Anaesthesia, obstetric. Complications, meningitis. Case  report CASE  1 A previously healthy 34-yr-old woman was admitted at term plus  9  days  in  early labour.  Her  first child had been delivered  by  emergency Caesarean section 3  yr  previously.  She  requested extradural analgesia an d  a  combined spinal—extradural procedure  w a s performed. Disposable pack  an d  needles were used, and  the  anaesthetist scrubbed an d  wore  a  sterile gown  and  gloves.  The  skin  wa s  prepared with unstained chlorhexidine  in  alcohol from  a  receptacle on  the  extradural trolley, dried with  a  sterile towel and then infiltrated with  2  % lignocaine.  The extradural space was located  a t  L2-3 with a standard Tuohy needle using loss  of  resistance  to  saline. A n 11. 9 cm, 27-gauge Whiteacre spinal needle  w a s passed through the Tuohy needle and after free flow of clear fluid, 0.25 % bupivacaine  1  ml, fentanyl 2 5  ug and  normal saline 0.5  m l  (total volume 2 ml) were given into  the  subarachnoid space.  The  spinal needle  w a s  withdrawn  and the  extradural catheter inserted. Immediate analgesia  w a s  achieved with  a sensory level  to T8  bilaterally.  The  solution  fo r extradural top-ups comprised 0.5 % bupivacaine 10 ml, fentanyl 100  ug and  normal saline 38 ml  in a 50-ml syringe. Three top-up doses  of  this solution were given during subsequent labour:  2 %  lignocaine 10 ml was also given before a lift-out forceps delivery which  w as  performed  f o r  failure  to  progress  in the second stage. A healthy baby girl was delivered 6.5  h after performing  the  combined spinal-extradural block. The patient was well the fol lowing m orning on the anaesthetic ward round,  but at  13:00, 21  h  after spinal injection,  sh e  developed  a  severe throbbing headache  an d  complained  o f  feeling faint  an d  with shortness  o f  breath.  On  examination  she was apyrexial, heart rate  was 68  beat min 1 , arterial pressure 90/60 mm Hg  an  ventilatory frequency 20 b.p.m ., but she was not cyanosed and had no neck stiffness. Four hours later  s he  w a s  unable  to  pass urine  an d  required catheterization.  At  18:00  the headache became more severe  a n d  she developed  a n expressive  an d  receptive dysphasia  an d  tingling  in the right side  o f  th e  face  an d  right  arm. We  were concerned that  she had  suffered  a  subarachnoid haemorrhage  o r a  stroke and she was transferred to  a neurological unit. After transfer  sh e  remained apyrexial  bu t  was then noted to have developed neck stiffness,  a  positive Kernig's sign and global aphasia. Neurological examination  o f  the cranial nerves  w as normal  an d  reflexes  o f  the limbs were present  an d symmetrical. One hour later  she had  a  temperature of 38 °C.  A CT  scan was performed which showed no abnormality. Lumbar puncture demonstrated CSF pressure  o f  12 cm H 2 O, WBC 725  x  10*  litre 1 (74%  polymorphs,  12 monocytes,  14 %  lym- phocytes)  an d  RBC 27 x  10 *  litre 1 . Increased  pro- tein (1.82  g  litre 1 )  an d  normal glucose (2.3 mmol litre 1 ) concentrations were seen  a n d  blood glucose concentration  wa s  5.0 mmol litre 1 .  No  organisms were seen  o r  subsequently cultured  in CSF or blood.  A  ful l blood count showed  a  haemoglobin concentration  at  10  g  dl 1 ,  WB C  16.9  x  10 9  litre 1 , granulocytes 10. 8 x 10 9  litre 1  and platelets 196  x  10 9 litre 1 .  A  provisional diagnosis  o f  either bacterial  or aseptic meningitis was made  and she  was given  i.v. chloramphenicol, benzylpenicillin, ampicillin,  flu- cloxacillin  an d  metronidazole.  The  antibiotics were chosen  to  cover both  the  common organisms known to cause meningitis  and,  in  view  of  the history  o f  a recent breach  o f  the dura, more unusual pathogens. The following  day,  within 10  h o f  commencing antibiotic treatm ent, the headache and neck stiffness had improved  a n d  aphasia  ha d  resolved.  The  anti- biotics were continued  for 5  days  and she w as discharged  on day 5  having made  a  complete S. A.  HARDING*,  MB BCHIR, FRCA,  R. E.  CoLListi  MB BS FRCA, B .  M.  MORGAN,  MB CHB,  FRCA,  Department  of  Anaesthetics Institute  of  Obstetrics  an d  Gynaecology, Queen Charlotte s  a nd Chelsea Hospital, Goldhawk Road, London W6 0XG. Accepted for publication: April  11 1994. Present address: * Royal Free Hospital, Pond Street, London NW3 2QG- t Royal London Hospital, Whitechapel, London  El  2AD. Correspondence  to  S.A.H.

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