Spinal anesthesia in a caesarian case after dry tap.

The case report here is a case of cesarean operation under subarachnoid block, which resulted after a failed lumber puncture, known to be "dry tap." The result is that it was uneventful surgery without any additive anesthetics being required after injecting 2.2 ml Bupivacaine 0.5% (H). Although cases have been reported with mixed experiences of dry tap and different causes are also explained, but still there is a need to find few other reasons for "dry tap." Hence, thought to present the case for putting forward a question that if there is any more cause for dry tap.

INTRODUCTION

Spinal anesthesia is common and is an easy procedure if we can locate a proper space and clear cerebrospinal fluid (CSF) flow. A major advantage of spinal anesthesia is its definitive endpoint, i.e., the free flow of CSF.[1] However, if it happens that no CSF comes even if being in the proper space then it is said to be a condition known as “dry tap.”[2] Although it's a rare incidence, but a very troublesome condition during a subarachnoid block (SAB). Even, if cases have been published regarding dry tap, but successful block without complication is rare among rarest cases.

CASE REPORT

A 20-year-old, parturient with 54 kg weight had been taken for cesarean section. On being posted for the surgery, she would only consent for regional anesthesia. She was attempted for spinal anesthesia at L3-4 interspace, then again attempted at L2-3 interspace in right lateral position using 25G spinal needles with midline approach, but failed to find CSF flow. Then, she was attempted with larger bore 23G spinal needle in a sitting position at L3-4 interspace with midline approach and although a “give” was felt, no CSF was seen. The procedure was attempted last at L2-interspace; again “give” was felt, but same result. Then, aspiration with a 2 ml syringe tried, but no CSF seen. At that time, 2.2 ml of Bupivacaine 0.5% heavy was injected, and incidentally a sensory block was achieved until T7 within 8 min and procedure carried out safely without any additional requirement of sedation or analgesics. It was only a small volume of Bupivacaine 0.5% so thought to be without any risk even if the block would have failed.

DISCUSSION

Causes of dry tap include a blocked needle, needle in the wrong space, spinal surgery previously, and low CSF pressures. It is possible that in patients with “absent” CSF or very low CSF pressure, the subarachnoid space is obliterated as the arachnoid “collapses” on the pia.[2] this increases the volume of the subdural space and may explain the absence of CSF. However, in this case, needle change was tried, tried with proper spaced identified, hydration was also proper; almost two ringers lactate was transfused when she was put to an operation table. It is a rare case in clinical practice and was uneventful; hence deliberation to present the case for putting ahead a question that if there is any more cause for dry tap. The query may arise for multiple attempts, but in this case the patient was not willing with general anesthesia and even if newer techniques have evolved like epidural stimulation,[3] but multiple attempts for spinal anesthesia still holds first-rate.[2] Again, a case was reported that dry tap lead to epidural abscess, but this case went uneventfully, where may be the patient's general condition and associated infection at a different site may also take a concern regarding any post-operative infections. However, this case was young and fit without any associated illnesses.

CONCLUSION

As Ramachandran and Pannusamy has also described that after multiple attempts and a distinct “give” with no CSF followed by a successful SAB.[2] Although there are many causes explained for dry tap as mentioned before, but after ruling out absence of all cause, still there was a dry tap. This case also can put front another wide scope of research on causes of “dry tap.”