To the Editor

In Dr. Ann Lofsky’s review of maternal arrest cases for The Doctors Company (Summer 2007 APSF Newsletter), she reported on 8 cases in which patients in labor suffered respiratory arrest following epidural anesthesia. For these cases, there was no mention as to whether a test dose was used before the full anesthetic dose was administered. All the other points noted had to do with the management of a total spinal block due, apparently, to inadvertent injection of the agent into the subarachnoid space.

The use of a test dose, to determine whether the needle or catheter is in the epidural or the subarachnoid, has been standard practice for more than 40 years. Whether that simple test was used and recorded is essential to support the statement in the summary: “the above cases are a testament to the fact that it still can and does occur—even when currently acceptable anesthesia practices are followed.”

This review treats respiratory arrest after epidural anesthesia as if it were bad luck, or the act of an evil spirit. That may be true from a lawyer’s point of view, but it is only a catastrophe (worst case scenario) when the “anesthesia provider” is not trained and equipped to deal with this complication by 1) being aware of its possibility, 2) having the necessary equipment at hand, and 3) having the training and skill to keep the patient ventilated and the circulation maintained. Dealing with an unexpectedly apneic patient is the trained anesthetist’s basic skill, but at least the basic equipment of an operating room needs to be at hand. (Note the one good outcome in which the anesthesiologist acted appropriately.) Epidural anesthesia under any other circumstances should not be attempted. It is rarely essential to the safe conduct of a delivery.

Van S. Lawrence, MD
Minneapolis, MN