Failure Of Spinal Anesthesia Research Articles

Factors associated with failed spinal anaesthesia for Caesarean sections in Mthatha general hospital, Eastern Cape, South Africa

Background: The use of spinal anaesthesia has increased in the last three decades, given that it is the recommended anaesthetic of choice for better foetal and maternal outcomes in Caesarean section. Failed spinal anaesthesia (FSA) exposes patients to unfavourable experience of pain and the potential complications of general anaesthesia that are being avoided in the first instance. This study determines the incidence and the predictors of failed spinal anaesthesia in pregnant women presenting for Caesarean section at Mthatha General Hospital, Eastern Cape.
 
 Methods: This descriptive cross-sectional study included 197 pregnant women scheduled for Caesarean section under spinal anaesthesia at Mthatha General Hospital from May 1 to August 30, 2013. A standard proforma was utilised for data collection on items of demographic, surgical and anaesthetic records of each parturient. The main outcome measure was the incidence of failed spinal anaesthesia (defined as partial or incomplete spinal block requiring conversion to general anaesthesia). 
 
 Results: The incidence of failed spinal anaesthesia was 11.7%, which was slightly higher in emergency Caesarean sections. In univariate analysis, previous anaesthesia, obesity, dry tap of cerebrospinal fluid (CSF), bloody CSF and duration of work experience less than one year were significantly associated with FSA in the cohort.
 
 Conclusion: The study found a high incidence of failed spinal anaesthesia during Caesarean section in this setting. Upskilling of doctors in spinal anaesthesia is urgently needed in the study setting. 
 
 (Full text of the research articles are available online at www.medpharm.tandfonline.com/ojfp)
 
 S Afr Fam Pract 2017; DOI: 10.1080/20786190.2017.1292696

Management of failed spinal anaesthesia for caesarean section.

Failed spinal anaesthesia for caesarean section (CS) may be partial or complete and the subsequent discomfort is the most commonly cited cause of litigation in obstetric anaesthesia. To determine if there is a standardised approach to: (i) testing the level of block of spinal anaesthesia; and (ii) the management of failed spinal anaesthesia for CS. A structured questionnaire to ascertain the current practice of testing the level of block and management of three different scenarios of failed spinal anaesthesia was distributed to 51 government hospitals in KwaZulu-Natal, South Africa (SA). All obstetric anaes-thetic service providers, ranging from interns to specialist anaesthetists, were invited to complete the questionnaire. A total of 375 responses were received from 42 of the 51 hospitals surveyed. Specialist anaesthetists managed failure of spinal anaesthesia significantly differently than other anaesthetic service providers. Specialists were more likely to convert to a general anaesthetic (GA), while others were more likely to repeat spinal anaesthesia or administer intravenous ketamine, midazolam and opioids. Only 212 respondents (56%) tested the level of block and there was no difference between the groups with regard to the method of assessment of height (p=0.15). Non-specialists, however, accepted a significantly lower level of block, using pinprick, than specialists (p=0.027), which could lead to a higher failure rate. More than one-third of non-specialists did not consider themselves competent to perform a GA and >90% of respondents agreed that a 'failed' spinal algorithm would be useful. There is a need for standardised assessment of the adequacy of spinal anaesthesia for CS in SA, as well as a failed spinal algorithm.

Total Spinal Anesthesia Failure: Have You Assessed the Sensory Anesthesia in Sacral Dermatomes?

Intrathecal local anesthetic maldistribution is a well-known cause of spinal anesthesia failure (SAF). This could potentially result in sensory blockade restricted to the sacral dermatomes. We sought to determine the overall incidence of SAF and the role of sacral dermatomes in differentiating between total and partial failures. Of the 3111 spinals prospectively examined, 194 (6.2%) were classified as failures. Of the 72 presumed total failures based on the initial assessment, evaluation of the sacral dermatomes revealed sensory blockade in 32 (44%; 95% confidence interval, 32.7%-56.6%). Sacral dermatome assessment after SAF may be important in safely guiding subsequent anesthetic management.

Factors associated with failed spinal anaesthesia for Caesarean sections in Mthatha general hospital, Eastern Cape, South Africa

Background: The use of spinal anaesthesia has increased in the last three decades, given that it is the recommended anaesthetic of choice for better foetal and maternal outcomes in Caesarean section. Failed spinal anaesthesia (FSA) exposes patients to unfavourable experience of pain and the potential complications of general anaesthesia that are being avoided in the first instance. This study determines the incidence and the predictors of failed spinal anaesthesia in pregnant women presenting for Caesarean section at Mthatha General Hospital, Eastern Cape.Methods: This descriptive cross-sectional study included 197 pregnant women scheduled for Caesarean section under spinal anaesthesia at Mthatha General Hospital from May 1 to August 30, 2013. A standard proforma was utilised for data collection on items of demographic, surgical and anaesthetic records of each parturient. The main outcome measure was the incidence of failed spinal anaesthesia (defined as partial or incomplete spinal block requiring conver...

The Impact of Gestational Age and Fetal Weight on the Risk of Failure of Spinal Anesthesia for Cesarean Delivery

(IJOA. 2016;26:8–14) The spread of spinal anesthesia may be increased during pregnancy, and hence pregnant women are considered to need a smaller dose of local anesthetic than nonpregnant women to achieve the same spinal block level. Data on spinal dosing for preterm (<37 wk of gestation) versus term (≥37 wk of gestation) parturients is limited. One earlier study found that standard doses of hyperbaric bupivacaine used for cesarean delivery failed to provide as high of a spinal block in women with preterm gestations compared to women at term. The aim of this study was to investigate the hypothesis that preterm gestation was associated with an increased risk of failed spinal anesthesia for cesarean delivery when compared with term gestation.

Peri-operative management of severe pre-eclampsia with kyphoscoliosis and poliomyelitis for emergency caesarean section

A 37 years old primigravida, 31 weeks gestation with severe preeclampsia [BP = 180/120 mm Hg] with severe kyphoscoliosis and polio affecting right lower limb was admitted in emergency with complaint of blurring of vision and pedal edema. An emergency caesarean section was conducted under general anaesthesia because of a failed spinal anaesthesia. Perioperative anaesthetic management and her postoperative course are discussed.

Avoiding failed spinal anesthesia: "Advik technique".

Avoiding failed spinal anesthesia: "Advik technique".

FAILED SPINAL ANESTHESIA

Objectives: To determine the frequency of failed spinal anesthesia in patientsundergoing caesarean section in a teaching hospital in Pakistan. Study Design: It was a cross– sectional study. Setting: Department of Anesthesia and Pain Management PAF HospitalSargodha. Period: January 2015 to May 2015. Methodology: A total of 293 pregnant patientsundergoing caesarean section under spinal anesthesia were included. After prehydration andessential monitoring, all patients were given spinal anesthesia with 25 G spinal needle at L3-L4 or L4-L5 level by 2nd year resident anesthesiologist under indirect supervision using 1.5 mlof hyperbaric spinal injection. Failure to achieve adequate block was managed by differentmodalities like sedation, analgesia with ketamine, repeat spinal anesthesia or to proceed withgeneral anesthesia. Results: Out of total of 293 patients, failed spinal occurred in 9 patients(3.07%). Out of these 9 patients, 02 patients (22.22%) were elective caesarean sections while07 cases (77.77%) were emergency caesarean sections. Conclusion: The chances of failedspinal anesthesia are more in emergency caesarean sections as compared to elective casesand failure rate of spinal anesthesia in PAF teaching hospital Sargodha is 3.07% which is slightlyhigher than 3%

The impact of gestational age and fetal weight on the risk of failure of spinal anesthesia for cesarean delivery

BackgroundThere are limited data about spinal dosing for cesarean delivery in preterm parturients. We investigated the hypothesis that preterm gestation is associated with an increased incidence of inadequate spinal anesthesia for cesarean delivery compared with term gestation. MethodsWe searched our perioperative database for women who underwent cesarean delivery under spinal or combined spinal-epidural anesthesia with hyperbaric bupivacaine ⩾10.5mg. The primary outcome was the incidence of inadequate surgical anesthesia needing conversion to general anesthesia or repetition or supplementation of the block. We divided patients into four categories: <28, 28 to <32, 32 to <37 and ⩾37weeks of gestation. The chi-square test was used to compare failure rates and a multivariable regression analysis was performed to investigate potential confounders of the relationship between gestational age and failure. ResultsA total of 5015 patients (3387 term and 1628 preterm) were included. There were 278 failures (5.5%). The incidence of failure was higher in preterm versus term patients (6.4% vs. 5.1%, P=0.02). Failure rates were 10.8%, 7.7%, 5.3% and 5% for <28, 28 to <32, 32 to <37 and ⩾37weeks of gestation, respectively. In the multivariable model, low birth weight (P<0.0001), gestational age (P=0.03), ethnicity (P=0.02) and use of combined spinal-epidural anesthesia (P<0.0001) were significantly associated with failure. ConclusionsAt standard spinal doses of hyperbaric bupivacaine used in our practice (⩾10.5mg), there were higher odds of inadequate surgical anesthesia in preterm parturients. When adjusting for potential confounders, low birth weight was the main factor associated with failure.

Repeat spinal anesthesia in cesarean section: A comparison between 10 mg and 12 mg doses of intrathecal hyperbaric (0.05%) bupivacaine repeated after failed spinal anesthesia: A prospective, parallel group study.

Background:Spinal anesthesia for cesarean section is not a 100% successful technique. At times, despite straightforward insertion and drug administration, intrathecal anesthesia for cesarean section fails to obtain any sensory or motor block. Very few studies and literature are available regarding repeat administration of spinal anesthesia and its drug dosage, especially after first spinal failure in cesarean section lower segment cesarean section (LSCS) due to fear of the excessive spread of drug. The aim of our study is to compare the outcome between two different doses of 0.5% hyperbaric bupivacaine repeated intrathecally after failed spinal.Materials and Methods:After taking informed consent and Ethical Committee approval this prospective, randomized single-blinded study was conducted in 100 parturients of American Society of Anesthesiologists I-II who were posted for elective LSCS and had Bromage score 0 and no sensory block even at L4 dermatome after 10 min of first spinal anesthesia; were included in the study. Group A (n = 50) patients received 2.4 ml and Group B (n = 50) patients received 2 ml of 0.5% hyperbaric bupivacaine respectively for administering repeat spinal anesthesia. Heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), oxygen saturation, respiratory rate and electrocardiogram were monitored both intra- and post-operatively and complications were recorded.Results:Incidence of high spinal, bradycardia, hypotension, respiratory complications, and nausea vomiting are significantly higher in Group A compared to Group B (P < 0.05). SBP, DBP, and HR were significantly low in Group A patients compared to Group B in the first 10 min (P < 0.05).Conclusion:Spinal anesthesia can be safely repeated in the cesarean section with 10 mg of 0.5% hyperbaric bupivacaine provided after first spinal anesthesia, the level of sensory block is below L4 and motor power in Bromage scale is 0.

Failed Obstetric Spinal Anesthesia in a Nigerian Teaching Hospital: Incidence and Risk Factors.

In a retrospective survey, we found 1% cases with complete and partial failure of spinal anesthesia for cesarean delivery between 2008 and 2010, which we attributed to underreporting because of the study design. In this prospective study, we determined the incidence of failed spinal anesthesia and identified the factors that increased its risk. This prospective, observational study consisted of all spinal anesthetics administered for cesarean delivery surgery from January 2011 to December 2013. Our definition of failure covered complete (preoperative) failure to achieve a pain-free operative condition and pain during surgery (intraoperative failure). Of a total of 3568 cesarean deliveries, there were 3239 (90.8%) spinal blocks, and the overall failure was 294 (9.1%). These were rescued by conversion to general anesthesia (22.8%) and repeating spinal (23.1%) and IV analgesic supplementation (54.1%). Analysis by logistic regression model indicated that factors associated with failure were the level of experience of the anesthesia provider as shown by senior registrar (adjusted risk ratio [RR], 1.4; 95% confidence interval [CI], 1.0-1.9), >1 lumbar puncture attempt (adjusted RR, 1.5; 95% CI, 1.1-1.9), and use of the L4/L5 interspace (adjusted RR, 1.7; 95% CI, 1.4-2.0). The rate of failed spinal anesthesia from this study was high. The independent predictors of failure were multiple lumbar puncture attempts, use of the L4/L5 interspace, and the level of experience of the anesthesia provider. It is imperative to develop clear guidelines to standardize our obstetric spinal anesthetic practice as well as the management of failures.

Unusual delayed presentation of cauda equina syndrome after failed spinal anesthesia.

Unusual delayed presentation of cauda equina syndrome after failed spinal anesthesia.

Failed spinal anesthesia in addicts: Is it an incidence or coincidence?

BackgroundDrug addiction remarkably increases morbidity and mortality among patients. Several cases of failed spinal anesthesia have been discovered in the clinical practice among addict patients. Different causes of failed spinal blocks have been mentioned in the literature.The aim of the study was to compare the success rate of spinal anesthesia in adult addicts and non-addicts.MethodologyThe study was conducted in Kasr al Ainy teaching hospital, Cairo University, Egypt. One hundred patients aged 20–50, ASA 1-2, both genders, undergoing lower abdominal or limbs surgeries under regional anesthesia, were included in the study. They were divided into 2 equal groups, relative to the addiction history to Marijuana, Cannabis, Tramadol, and Clonazepam. Group [NAD] non-addicts (n = 50); and Group [AD] addicts (n = 50). The success rate, onset, duration of sensory and motor blocks were evaluated. Hemodynamic data were collected, and any complications due to the drugs used or due to spinal anesthesia were recorded.ResultsThe incidence of failure of the spinal anesthesia was higher in Group [AD] (33%) than Group [NAD] (4%), (p < 0.05). There was delay in the onset time and decreased duration of both sensory and motor blocks in the addict groups compared to non-addicts. All previous findings showed statistical significant difference (P < 0.05). Hypotension (p < 0.05) and nausea occurred more in addict groups than in non-addicts. No other complications were encountered in the study.ConclusionThe incidence of failure of the intrathecal anesthesia seemed to be higher in the addict than in non-addict patients. Redo intrathecal injection with a top up 1/2 of the initial dose resulted in success of the block in all failed cases. There was a slower onset and decreased duration of both sensory and motor blocks, with higher incidence of hypotension and nausea more in the addict patients than in non-addicts.

Inadequate spinal anesthesia in a parturient with Marfan's syndrome due to dural ectasia.

Inadequate spinal anesthesia in a parturient with Marfan's syndrome due to dural ectasia.

Dural ectasia.

Dural ectasia is one of the likely causes of incomplete or failed spinal anaesthesia. Its association with diseases like Marfans syndrome, neurofibromatosis, osteogenesis imperfecta, vertebral fracture, postopertative adhesions, trauma etc., is often overlooked as a reason for inadequate spinal anaesthesia. Greater than normal volume of cerebrospinal fluid in the lumber theca in dural ectasia is postulated to restrict the spread of intrathecally injected Local anaesthetic. Here, we report a case of failed spinal anaesthesia but successful epidural anaesthesia in later setting in a patient with dural ectasia.

Repeat spinal anesthesia after a failed spinal block in a pregnant patient with kyphoscoliosis for elective cesarean section

Pregnant patients with kyphoscoliosis present a unique challenge during their anesthetic management due to the physiologic changes of pregnancy and deformity of the spine leading to pulmonary abnormalities. We present a case report of a 29-year-old second gravida with kyphoscoliosis who successfully underwent elective caesarean section under repeat spinal block after failure of first spinal anesthesia.

English

BACKGROUND: Since its introduction to clinical use in 1899 by August Bier, spinal anaesthesia has stood the test of time. In the last five decades it has gained in popularity. Apart from avoiding the complications of general anaesthesia, it is a simple, reliable and a cheap procedure and is relatively easy to master. But sometimes we come across partial or complete failure of spinal anaesthesia. In our rural setup to cut the cost of anaesthesia we give second spinal anaesthesia, immediately. METHODS: This prospective study was undertaken in our institution for three years, from March 2010 to April 2013 to 1) determine the incidence of failed spinal anaesthesia, 2) manage such cases by giving a second spinal immediately, if surgery has not started 3) find out the intraoperative, postoperative and late complications of the second spinal, if any. All patients undergoing lower abdominal, perineal and lower limb surgeries were included. After ten minutes of giving the spinal anaesthesia with bupivacaine, if no effect was seen as determined by sensory level and motor blockade, a second spinal was given preferably at a higher level. Demographic, anaesthetic and surgical data were collected and analysed. Patients were followed up in the postoperative room and in the ward till their discharge, for any possible complications. Patients were asked to report to the hospital if they developed any problems after discharge. RESULTS: 140 patients out of a total number of 2450 developed partial or complete failure. 62 complained of pain after surgery had started. Of these 62, 15 were managed by giving intravenous analgesia, seven by N2O/O2 50:50 inhalation, and thirteen by manipulating the table. 27 were converted to general anaesthesia. Out of 140 patients, 78 /2450(3.18%) were given a second spinal. In all these patients, the second injection acted well giving good muscle relaxation and adequate sensory block. One patient developed high spinal soon after the second injection. Another patient developed severe bradycardia and hypotension during the surgery. There were no complications in the postoperative period. None of the patients who have come for follow up; have reported any problems related to the second spinal anaesthetic to date. CONCLUSION: Repeating a spinal anaesthesia after a failed one is a good method of management, if conditions permit and proper care is taken. By this all the indications for giving spinal anaesthesia in the first instance is well maintained.

Postoperative neurological aggravation after anesthesia with sevoflurane in a patient with xeroderma pigmentosum: a case report

IntroductionXeroderma pigmentosum is a rare autosomal recessive disease that causes changes in skin pigmentation, precancerous lesions and neurological abnormalities. It is a defect in the nucleotide excision repair mechanism. It has been reported that volatile anesthetics has a possible genotoxic side effect and deranged nucleotide excision repair in cells obtained from a patient with xeroderma pigmentosum.We report an unusual case of postoperative neurological aggravation in a patient with xeroderma pigmentosum anesthetized with sevoflurane.Case presentationA 24-year-old African woman, who has had xeroderma pigmentosum since childhood, was admitted to our hospital for a femoral neck fracture. A preoperative physical examination revealed that she had a resting tremor with ataxia. She had cutaneous lesions such as keratosis and hyperpigmentation on her face and both hands. There was no major alteration of cognitive function, muscular strength was maintained and her osteotendinous reflexes were preserved. Surgical fixation was performed under general anesthesia after the failure of spinal anesthesia. All parameters were stable during surgery. When she woke up four hours later, the patient presented with confusion and psychomotor agitation, sharpened reflexes and the Babinski reflex was present. Her postoperative test results and a magnetic resonance imaging scan were unremarkable. It was suggested that sevoflurane had had a probable deleterious effect on the neurological status of this patient.ConclusionThe anesthetizing of a patient with xeroderma pigmentosum is associated with a risk of worsening neurological disorders. At present, there are no clear recommendations to avoid the use of volatile agents in the anesthetic management of patients with xeroderma pigmentosum. More clinical and experimental research is needed to confirm the sensitivity of patients with xeroderma pigmentosum to sevoflurane and other halogenated anesthetics.

Spinal subarachnoid hematoma after spinal anesthesia

Spinal subarachnoid hematoma after spinal anesthesia

PHP94 Effectiveness and Cost-Benefit of a Bupivacaine Physician Educational Programme in Minimizing the Spinal Anesthesia Failure Rate: Report from a Tertiary-Care Hospital in Central Taiwan

PHP94 Effectiveness and Cost-Benefit of a Bupivacaine Physician Educational Programme in Minimizing the Spinal Anesthesia Failure Rate: Report from a Tertiary-Care Hospital in Central Taiwan