In Reply:—

We appreciate the comments by Drs. Verma and Platt about our letter to the editor 1and would like to respond to each comment separately.

First, we did not consider the test dose to be negative. The initial increase in heart rate from 100 to 138 beats/min caused concern, and we removed the epidural catheter and replaced it with a new catheter with no difficulty. Because we suspected the patient’s initial symptoms, such as tachycardia and dizziness, to be positive responses to the test dose, we perhaps missed the rapidly developing hypoglycemia and did not check her blood sugar concentration at the beginning of this event.

Second, we disagree with the assessment of Drs. Verma and Platt that all symptoms and signs shown by this patient, such as severe hypotension and acute hypoglycemia, can be attributed to an inadvertent intravenous injection of a test dose of 3 ml lidocaine.

Third, to state that we noted no change in the patient’s pulse or blood pressure after combined spinal–epidural analgesia is not true. We reported profound hypotension and described in detail how we treated her symptoms.

Fourth, we administered 5% dextrose infusion because this solution was readily available in our cart. Maternal blood sugar concentration increased safely and without any delay, with complete alleviation of all symptoms.

Finally, acute hypoglycemia after regional anesthesia in parturients may not be such a rare occurrence. I wish to draw the attention of Drs. Verma and Platt to a recent case report 2in which the authors described the occurrence of profound hypoglycemia in a healthy parturient to whom epidural anesthesia was administered for labor.

Crites J, Ramanathan J: Acute hypoglycemia following combined spinal-epidural anesthesia (CSE) in a parturient with diabetes mellitus. A nesthesiology 2000; 93: 591–2
Jacobs JS, Vallejo R, DeSouza GJ, TerRiet MF: Severe hypoglycemia after labor epidural analgesia. Anesth Analg 2000; 90: 892–3