Case reportIn 1987, a 27-yr-old healthy woman presented for an elective Caesarean section. She had had a previous Caesarean section under general anaesthesia without difficulty. There were no problems found on history or physical examination. The patient decided after discussion with her general practitioner and anaesthetist to have an epidural an- Accepted for publication 25th June, 1993. aesthetic for pain control. Haemoglobin and urinalysis were normal. She was given 30 ml Na citrate outside the OR.At 08:00 a continuous epidural catheter was inserted with the patient in the seated position with no difficulty. The patient was positioned with a wedge under her right hip. Intermittent injections to a total of 22 ml lidocaine 2% with epinephrine were placed in the epidural space. One litre of normal saline was given /v. The monitors were a hard copy blood pressure (BP) showing normal fluctuating BP and pulse and an ECG. The epidural level was tested and found to be at the T~_ 6 level. Surgery started 20 min after the epidural was inserted. The patient was carrying on a normal social conversation.At 08:45 (as the head of a normal crying infant was delivered through the anterior abdominal wall) the mother suddenly complained of shortness of breath (SOB), began to hyperventilate, coughed and became cyanosed. The blood pressure decreased, the sinus heart rate increased, and she may have suffered a seizure (there was thrashing of both arms). Almost immediately BP and pulse on the Dinemapp recorder were undetectable (Table I -8:48) but the ECG showed sinus tachycardia. The airway was managed initially with mask and oxygen and then the trachea was intubated without difficulty. Breathing was managed initially with mask ventilation with oxygen and continued with bag ventilation through the endotracheal tube. There was no bronchospasm and air entry was equal bilaterally.Circulation was managed by the infusion of fluid, drugs which included ephedrine, epinephrine, NaHCO3, isuprel and atropine, and cardiac massage. Other drugs given included Na citrate preoperatively, succinylcholine, atracurium, thiopentone, and oxytocin. At various times another anaesthetist, two intensive care physicians and nurses were in the operating room observing and helping with the resuscitation. These manoeuvres were successful in returning blood pressure but the patient remained cyanosed in spite of an adequate blood pressure and positive pressure ventilation with 100% 02.The blood pressure decreased a second time (Table I -9:01) and again the patient was resuscitated. The fwst inadequate blood pressure (taken from the Dinemapp) was recorded at 08:48 (only one reading at this level). The total time between adequate blood pressures was seven minutes. The total time of inadequate blood CAN J ANAESTH 1993 / 40:I0 / pp 971-80