[Case of postoperative increased anesthesia level with spinal anesthesia]

A patient, 35 weeks and 2 days gestation with twins, was scheduled for cesarean section. Spinal anesthesia was induced with the patient in lateral decubitus position using 2.2 ml hyperbaric bupivacaine 0.5% at the L3-4 interspace. The patient was placed immediately in supine position. After 5 min, sensory block level was confirmed T5. Operation was performed with no complications. Patient left the operating room 60 min after the induction. In the ward, the patient complained of respiratory distress and inability to move hands. Sensory block level reached C4 2 hours after spinal anesthesia induction. Four hours after induction, patient's sensory and motor paralysis recovered completely. In our operating room, patient enters and leaves with moving slide hatch machine. So patient's body moves to right and left side. We think that the increased anesthesia level was caused by this rolling of the body. We must be cautious about the increased anesthesia level when spinal anesthesia is induced.