|Year : 2016 | Volume
| Issue : 1 | Page : 31-33
Transient aphonia following spinal anesthesia in a parturient: A case report
Renu Bala1, Geeta Ahlawat1, Susheela Taxak1, Savita Singhal2, Jaswant Singh1
1 Department of Anaesthesiology and Critical Care, Pt. BD Sharma Post Graduate Institute of Medical Sciences (PGIMS), Rohtak, Haryana, India
2 Department of Obstetrics and Gynaecology, Pt. BD Sharma Post Graduate Institute of Medical Sciences (PGIMS), Rohtak, Haryana, India
|Date of Web Publication||22-Apr-2016|
Dr. Jaswant Singh
House No. 5, Type III, Maharshi Dayanand University (MDU), Maharshi Dayanand University Campus, Rohtak - 124 001, Haryana
Source of Support: None, Conflict of Interest: None
Spinal anesthesia is the preferred technique of administering anesthesia for elective cesarean section (CS). Hypotension, failed spinal anesthesia, postdural-puncture headache, cauda equina syndrome are a few complications that may occur but neurological complications particularly aphonia are quite rare. The use of lipophilic opioids as adjuvants with local anesthetics are considered as culprit but the exact mechanism remains unidentified. We report such presentation in our patient and discuss the likely cause.
Keywords: Cesarean section (CS), neurological complications, opioids, spinal anesthesia
|How to cite this article:|
Bala R, Ahlawat G, Taxak S, Singhal S, Singh J. Transient aphonia following spinal anesthesia in a parturient: A case report. J Obstet Anaesth Crit Care 2016;6:31-3
|How to cite this URL:|
Bala R, Ahlawat G, Taxak S, Singhal S, Singh J. Transient aphonia following spinal anesthesia in a parturient: A case report. J Obstet Anaesth Crit Care [serial online] 2016 [cited 2019 Dec 13];6:31-3. Available from: http://www.joacc.com/text.asp?2016/6/1/31/181076
| Introduction|| |
Spinal anesthesia has become the method of choice for anesthesia in patients undergoing elective cesarean delivery. The various advantages are rapid administration and onset of anesthesia, reduced risk of systemic toxicity and aspiration, and direct experience of childbirth.  Though it is associated with a myriad of complications, neurological complications are unusual.  They are mostly found in patients who have received opioids as adjuncts with local anesthetics for labor analgesia or cesarean section (CS).  Various mechanisms have been proposed but a clear mechanism has not been identified. We, hereby, report a case of transient aphonia after intrathecal administration of bupivacaine and fentanyl for CS.
| Case Report|| |
A 34-year-old parturient weighing 75 kg and having a height of 167 cm was scheduled to undergo elective CS due to a bad obstetric history. She had no past significant history and the investigations were within normal range. Her antenatal course was unremarkable. Tablet ranitidine 150 mg and tablet metoclopramide 10 mg orally were given 2 h preoperatively as premedication. The preoperative vitals were within normal limits. Informed consent was obtained and she was taken up for surgery. In the operating room, standard monitors comprising heart rate, ECG, noninvasive blood pressure (BP), and pulse oximetry were applied. Preloading was done with 1,200 mL of ringer lactate (RL) solution. Under all aseptic precautions, spinal anesthesia was administered in left lateral position in L 3-4 space through median approach using 23G Quincke needle. 2 mL of 0.5% bupivacaine with 0.5 mL (25 μg) fentanyl was injected intrathecally after a clear flow of cerebrospinal fluid (CSF) was obtained. The patient was turned supine with left lateral tilt by placing a wedge below right hip. There was sudden fall of BP (70/30 mmHg) after 3 min of the administration of spinal block but heart rate was 70 bpm and SpO 2 -100%. It was managed with rapid infusion of 300 mL of RL and injection ephedrine 5 mg + 5 mg. The BP improved to 100/60 mmHg, sensory level of block was T 6 and motor blockade as per modified Bromage score was 3. Surgery was started and a 3.8 kg baby with Apgar score of 8 at 1 min and of 10 at 5 min was delivered. After 5 min of delivery of the baby, the patient complained of difficulty in vocalizing and communicated in a depressed voice along with tense gesture and then within 1 min she developed aphonia. She seemed very anxious, trying to move her upper torso and head side-to-side and by lifting the upper limbs imitating her inability to vocalize. The level of block was checked, which was T 6 , and hemodynamics and SpO 2 were within normal range although she was tachypneic [respiration rate (RR) = 28/min]. She was reassured repeatedly and spontaneous ventilation was maintained with 100% oxygen using Bain's circuit. The aphonia gradually resolved after 10 min and she could vocalize. Rest of the intraoperative period was uneventful. She was subjected to detailed neurological examination that was unremarkable. Magnetic resonance imaging (MRI) of brain, color Doppler, and electroencephalograph (EEG) were normal.
| Discussion|| |
The neurological complication particularly aphonia is quite rare following spinal anesthesia for elective CS. The etiopathogenesis of this uncommon complication could be TIA, absence seizures, or cerebral thromboembolism. The differential diagnosis of such clinical presentation could be high spinal block, TIA, absence seizures, subdural block, or use of opioids. Though sudden hypotension occurred in our patient, other features of high sympathetic blockade such as bradycardia and pupillary dilatation were absent. Level of sensory blockade was also T 6 .
Hypotension following spinal anesthesia is a known complication and its incidence in parturient can be as high as 80%.  In the present case preloading was done with crystalloid (500 mL RL) prior to subarachnoid block but it may not have prevented ensuing hypotension. Though preloading with colloid has been recommended by few authors to prevent hypotension following subarachnoid block  but this is not a standard practice due to the concerns of coagulation disorders, effects on renal functions, and anaphylactic reactions.
Transient ischemic attack (TIA) is a transient neurological event lasting for few minutes and occurs due to hypotension, hypoxia, or embolism. Sudden hypotension could have decreased blood supply to brain [cerebral perfusion pressure (CPP) = Mean arterial pressure (MAP)-intracranial pressure (ICP)] causing TIA. Postoperative MRI scan (brain) was done that ruled out its presence.  Absence seizure was not considered as there was no history of similar episode in the past and EEG was normal. Subdural injection of drug has varied presentation such as excessive sensory blockade with sparing of sympathetic functions, failed spinal anesthesia, significant motor weakness of upper extremities, and delayed or faster than usual onset of block.  The etiology is rostral spread of drug followed by involvement of the brain stem.  Subdural block was ruled out as a possibility since the patient did not have any feature suggestive of subdural block.
The use of lipophilic opioid (fentanyl) as an adjuvant to local anesthetics for intrathecal administration has known to cause unusual complications such as dysphagia, facial numbness, and aphasia.  The rapid rostral spread of opioids through CSF affecting speech area or cranial nerves is the most likely mechanism. Moreover, the transient nature of symptoms suggest opioid rather than local anesthetic as culprit, as rapid clearance of fentanyl from CSF resulted in disappearance of symptoms. The position of patient and baricity of the drug at the time of block had been found to affect the rostral spread of the drug. The presence of wider pelvis during pregnancy makes the vertebral column inclined toward the head end in lateral position, which may increase the cephalad spread of the drug. The baricity of local anesthetic and opioid may be available but that of mixture is still unknown.  An in-vitro study, has shown that the addition of opioid to isobaric bupivacaine decreases the baricity of the solution. 
The exact incidence of such events is unknown as there are few anecdotal case-reports in the literature where aphonia alone or accompanied with neurological symptoms have occurred after spinal anesthesia. ,,,,,, Opioids (fentanyl or sufentanil) were used in most of them and there was wide range of time interval after which symptoms occurred (4 min to 1 h) and lasted for 5-90 min. In the present case it occurred around 12 min following subarachnoid block and lasted for 10 min. It has been described as self-limiting similar to our case presentation. Furthermore, in none of these patients aphonia was preceded by hypotension but in our case it was; so TIA remains a possibility. Most of the incidences are reported in parturients. However, Tripat et al. reported such presentation in a patient undergoing orthopedic surgery and hyperbaric bupivacaine was administered intrathecally without any opioid. The authors speculated subdural extension of local anesthetic as the most likely mechanism. 
| Conclusion|| |
In conclusion, a case of temporary aphonia following intrathecal administration of bupivacaine and fentanyl was encountered. Though, it was transient and self-limiting it caused significant distress to the patient. If such event occurs, reassurance alongwith watchful expectancy should be followed. Furthermore, control of BP is very crucial and hypotension should never be undermined.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
American Society of Anesthesiologists Task Force on Obstetric Anesthesia. Practice guidelines for obstetric anesthesia: An update report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia. Anesthesiology 2007;106:843-63.
Lamacraft G. Complications associated with regional anaesthesia for caesarean section. South Afr J Anaesth Analg 2004;10:15-20.
Ray BR, Baidya DK, Gregory DM, Sunder R. Intraoperative neurological event during cesarean section under spinal anesthesia with fentanyl and bupivacaine: Case report and review of literature. J Anaesthesiol Clin Pharmacol 2012;28:374-7.
Levin A, Datta S, Segal S. The effect of posture on hypotension after spinal anaesthesia for caesarian section. Anesthesiology 1998;88:A10.
Emmett RS, Cyna AM, Andrew M, Simmons SW. Techniques for preventing hypotension during spinal anaesthesia for caesarean section. Cochrane Database Syst Rev 2002;CD002251.
Merwick A, Kelly PJ. Transient ischaemic attack clinics and management of transient ischaemic attacks. Curr Opin Neurol 2011;24:50-8.
Agarwal D, Mohta M, Tyagi A, Sethi AK. Subdural block and anaesthetist. Anaesth Intensive Care 2010;38:20-6.
Parlow JL, Money P, Chan PS, Ramond J, Milne B. Addition of opioids alters the density and spread of intrathecal local anesthetics? An in vitro
study. Can J Anaesth 1999;46:66-70.
Currier DS, Levin KR, Campbell C. Dysphagia with intrathecal fentanyl. Anesthesiology 1997;87:1570-1.
Tripat B, Ruchi G, Sonika T. Transient aphasia following spinal anaesthesia in an orthopaedic patient. South Afr J Anaesth Analg 2012;18:346-7.
Hamilton CL, Cohen SE. High sensory block after intrathecal sufentanil for labor analgesia. Anesthesiology 1995;83:1118-21.
Cohen SE, Cherry CM, Holbrook RH Jr, el-Sayed YY, Gibson RN, Jaffe RA. Intrathecal sufentanil for labor analgesia--sensory changes, side effects, and fetal heart rate changes. Anesth Analg 1993;77:1155-60.
Fragneto RY, Fisher A. Mental status change and aphasia after labor analgesia with intrathecal sufentanil/bupivacaine. Anesth Analg 2000;90:1175-6.
Kuczkowki KM, Goldsworthy M. Transient aphonia and aphagia in a parturient after induction of combined spinal-epidural labor analgesia with subarachnoid fentanyl and bupivacaine. Acta Anaesthesiol Belg 2003;54:165-6.