A lumbar epidural catheter is placed for an elective cesarean section. Twenty-five minutes after the full dose, the patient has nasal congestion. The most likely explanation is?

A lumbar epidural catheter is placed for an elective cesarean section. Twenty-five minutes after the full dose, the patient has nasal congestion. The most likely explanation is?

• A. A total spinal from inadvertent subarachnoid injection of local anesthetic
• B. A total sympathectomy and nasal congestion from a high level of blockade
• C. Volume overload
• D. Amniotic fluid embolism

Answer: (B)

High neuraxial blockade causing sympathetic depletion explains the nasal congestion. When the epidural spread reaches high thoracic or cervical levels, the sympathetic outflow to the head and neck is blocked. This removes the normal vasoconstrictor input to the nasal mucosa, allowing unopposed parasympathetic activity to dominate. The result is vasodilation and engorgement of the nasal mucosa, producing nasal congestion. This sign appears after the block has risen to a high level, which fits a situation where a full dose has spread upward. Why the other ideas fit less well: a total spinal would produce rapid, widespread motor and sensory loss with potential respiratory compromise soon after placement, not isolated nasal congestion. Volume overload would cause signs like pulmonary edema and generalized edema, not a localized nasal symptom. Amniotic fluid embolism presents with sudden cardiovascular collapse and DIC, not a benign nasal congestion sign.

High neuraxial blockade causing sympathetic depletion explains the nasal congestion. When the epidural spread reaches high thoracic or cervical levels, the sympathetic outflow to the head and neck is blocked. This removes the normal vasoconstrictor input to the nasal mucosa, allowing unopposed parasympathetic activity to dominate. The result is vasodilation and engorgement of the nasal mucosa, producing nasal congestion. This sign appears after the block has risen to a high level, which fits a situation where a full dose has spread upward.

Why the other ideas fit less well: a total spinal would produce rapid, widespread motor and sensory loss with potential respiratory compromise soon after placement, not isolated nasal congestion. Volume overload would cause signs like pulmonary edema and generalized edema, not a localized nasal symptom. Amniotic fluid embolism presents with sudden cardiovascular collapse and DIC, not a benign nasal congestion sign.