ACUTE AIRWAY-OBSTRUCTION DURING SPINAL-ANESTHESIA FOR CESAREAN-SECTION

A 30-year-old primiparous Caucasian woman with known placenta praevia required an emergency caesarean section for a mild antepartum haemorrh age at the onset of spontaneous term labour. Following intravenous pre hydration with 500 ml gelatin colloid (Haemaccel(TM)), spinal anaesthe sia was induced in the sitting position with 2.6 ml of 0.5% hyperbaric bupivacaine (13 mg). The patient was then placed in the recumbent pos ition with left lateral tilt, whereupon she suddenly became dyspnoeic. A generalized erythematous urticarial rash with associated facial, pe riorbital, glossal and perioral oedema became evident. Although matern al blood pressure remained within normal limits, emergency conversion to general anaesthesia with tracheal intubation was necessary to secur e the airway. Laryngoscopy revealed gross submucosal, epiglottic and p haryngeal oedema, characteristics of the syndrome of angioneurotic oed ema, which may complicate an anaphylactoid reaction. After the airway was secured with a cuffed endotracheal tube, caesarean section proceed ed uneventfully and a healthy male infant was delivered. Maternal faci al and airway oedema subsided and extubation was performed in intensiv e care 2 h later. Life-threatening airway obstruction often accompanie s angioneurotic oedema. Since parturients have a higher incidence of d ifficult airway management than the general population, anaphylactoid reactions presenting as angioneurotic oedema pose a particular challen ge for the anaesthetist. The lower incidence of allergy associated wit h hydroxyethyl starch (Hetastarch) may make it a more appropriate choi ce of colloid in this setting. However, the balance of evidence now su ggests that vasopressors, particularly ephedrine, are superior to flui ds for maintenance of blood pressure during regional anaesthesia for c aesarean section.