Complete failure of spinal anaesthesia in obstetrics

Failed spinal anesthesia for cesarean delivery: prevention, identification and management

PURPOSE OF REVIEW

There is an increasing awareness of the significance of intraoperative pain during cesarean delivery. Failure of spinal anesthesia for cesarean delivery can occur preoperatively or intraoperatively. Testing of the neuraxial block can identify preoperative failure. Recognition of the risk of high neuraxial block in repeat spinal in case of preoperative failure is important.

RECENT FINDING

Knowledge of risk factors for block failure facilitates prevention by selecting the most appropriate neuraxial procedure, adequate intrathecal doses and choice of technique. Intraoperative pain is not uncommon, and neither obstetricians nor anesthesiologists can adequately identify intraoperative pain. Early intraoperative pain should be treated differently from pain towards the end of surgery.

SUMMARY

Block testing is crucial to identify preoperative failure of spinal anesthesia. Repeat neuraxial is possible but care must be taken with dosing. In this situation, switching to a combined spinal epidural or an epidural technique can be useful. Intraoperative pain must be acknowledged and adequately treated, including offering general anesthesia. Preoperative informed consent should include block failure and its management.

Incidence and factors associated with failed spinal anaesthesia among patients undergoing surgery: a multi- center prospective observational study

BACKGROUND

Failed spinal anaesthesia causes prolonging of operation time, insufficient analgesia for surgery and needs repeating spinal anaesthesia which in turn causes local anaesthesia toxicity, high spinal and total spinal, and conversion to general anaesthesia. However, the problem remains unexplored in Amhara regional state comprehensive specialized hospitals.

OBJECTIVE

To determine incidence and factors associated with failed spinal anaesthesia among patients undergoing surgery in selected Amhara National Regional State comprehensive specialized hospitals, Northwest Ethiopia, 2023.

METHODS

Multi-center prospective observational study was conducted. Data was collected using questionnaire and checklist. All consecutive scheduled emergency and elective patients were included in the study. Data was transformed from Epi data to SPSS and logistic regression analysis was done. Both crude and adjusted odds ratio were used to assess the strength of association. Variables with a p-value of less than 0.05 were considered as statistically significant.

RESULTS

A total of 532 patients were included in this study with a response rate of 98%. Incidence of failed spinal anaesthesia was 22.4% (CI = 19-25.9). Emergency surgery (AOR = 7.01, CI = 4.5-12.7), dose of bupivacaine of ≤ 10 mg (AOR = 3.02, CI = 1.3-10.2), work experience of anaesthetist < 2 years (AOR = 3.1, CI = 1.7-5.72), bloody CSF (AOR = 8.5, CI = 2.53-18.5), hyperbaric local anaesthetic drug (AOR = 3.3, 95% CI = 3.2-8.2) and local anaesthetist without adjuvants (AOR = 5.25, CI = 2.62-14.2) were associated failed spinal anaesthesia.

CONCLUSION AND RECOMMENDATION

The incidence of failed spinal anaesthesia was high in Amhara Region comprehensive specialized hospitals. We suggest that anaesthesia providers should minimize failure by using adjuvants and appropriate dose of local anaesthetic. Additionally, simulation training should be given for anaesthesia trainees to improve their skills and to produce competent professionals.

Pragmatic approach to neuraxial anesthesia in obstetric patients with disorders of the vertebral column, spinal cord and neuromuscular system

Neuraxial anesthesia provides optimal labor analgesia and cesarean delivery anesthesia. Obstetric patients with disorders of the vertebral column, spinal cord and neuromuscular system present unique challenges to the anesthesiologist. Potential concerns include mechanical interference, patient injury and the need for imaging. Unfortunately, the existing literature regarding neuraxial anesthesia in these patients is largely limited to case series and rare retrospective studies. The lack of practice guidance may lead to unwarranted fear of patient harm and subsequent avoidance of neuraxial anesthesia for cesarean delivery or neuraxial analgesia for labor, with additional risks of exposure to general anesthesia. In this narrative review, we use available evidence to recommend a framework when considering neuraxial anesthesia for an obstetrical patient with neuraxial pathology.

Incidence and Causes of Failed Spinal Anesthesia

Introduction: Spinal anesthesia (SA) is one of the most frequently applied anesthesia procedures today. However, SA failure rate varies between 1 and 17%. The age of the patient, the position at which the procedure is performed, or the characteristics of the technical operation can affect success. In this study, we aimed to compare the most frequent SA failures according to the types of surgery and causes of failure. The results of SA procedures performed in a university hospital were compare to those published in the current literature. Materials and Methods: After obtaining ethics committee ­approval for our study, the hospital archives were examined retrospectively for 1 year with respect to SA procedures. SA application and failure rates were examined. Three or more SA attempts, failed dural puncture, or unsuccessful injection, and anesthesia applications that did not provide sufficient sensory block for surgery despite successful drug treatment were defined as failure. Results: Of all anesthesia procedures, SA was applied at a rate of 23.5%. Our SA failure rate was calculated as 16.6%. Considering a single surgical procedure, obstetric anesthesia was the most common surgery with failed SA (28.7%). The most common cause of failure was insufficient analgesia (32.9%). Discussion: SA failure rates were observed to be in a variable distribution range in the literature, and in some studies, SA failure was defined as a block that did not occur despite a full dose and successful injection, and this rate was found to be 3.9%. The high rate in our study group may be explained by differences in the definition of SA: blocks performed with several trials and any block that could not be applied were also recorded as SA failure. The reasons for failing to apply this procedure is an issue that is worth examining also in terms of patient satisfaction and safety, which is an important issue. Conclusion: Although the definition of unsuccessful SA is confusing, SA failure rates are worth examining and improving for each hospital.

Local anesthetic resistance in a Crohn's patient undergoing cesarean delivery

INTRODUCTION

Patient resistance to local anesthetics is rarely considered as the cause of regional anesthesia failure.

CASE REPORT

We report a case of resistance to local anesthetics in a patient with Crohn's disease who underwent cesarean section under continuous spinal anesthesia.

DISCUSSION

Resistance to local anesthetics may be more common than we think, especially among patients with chronic pain. Providers should consider local anesthetic resistance when regional anesthesia is unsuccessful. Further research is needed to determine if skin wheal tests and/or a different local anesthetic could improve results.

THE COMPLICATIONS OF SPINAL ANESTHESIA IN OBSTETRIC AND GYNECOLOGICAL SURGICAL PROCEDURES

Background: The proper use of spinal anesthesia in surgical procedures will minimize patient’s referral. The objectives of the study were to determine the immediate and late complications of spinal anesthesia in obstetric and gynecological surgical procedures in our population. Material and Methods: This cross-sectional study was conducted in the Department of Gynecology and Obstetrics, Moulvi Ameer Shah Memorial Hospital, Peshawar, Pakistan from January 2014 to December 2014. Sample size was 790, selected through consecutive sampling technique. All routine and emergency obstetrical and gynecological cases were included. The exclusion criteria were those having hypotension, shock, coagulopathy, prolonged surgeries, patient’s refusal and local spinal disease. The demographic variables were; number of attempts, failure of anesthesia, vomiting, hypotension, respiratory problems, pain, Puncture site pain, and post dural puncture headache. All variables being categorical were analyzed by frequency and percentages using SPSS Version 16.0. Results: Out of 790 obstetrics and gynecology patients undergoing spinal anesthesia, there were 752 (95.2%) patients anaesthetized on first attempt whereas 38 (4.8%) required >1 attempts. Spinal anesthesia failed in 17 (2.1%) cases, partially failed in 15(1.9%). Post-operative mild hypotension was observed in 25 (3.1%) patients and severe hypotension in 4 (0.5%) cases. Respiratory problems were noted among 12 (1.9%). Patient’s Post-operative pain was observed in 28 (3.5%) patients. Nausea and vomiting were noted in 68 patients (8.6%).Late complications include post-operative mild to moderate pain in 65 (8.2%), severe in 15 (1.9%). Puncture site pain was observed in 8 (1.0%) of patients. Severe post dural puncture headache was noted in 3 (.38%). Conclusion: Spinal anesthesia in obstetric and gynecological surgical patients is easy to administer, safer and effective.

Integrated System Design: Promoting the Capacity of Sociotechnical Systems for Adaptation through Extensions of Cognitive Work Analysis

This paper proposes an approach for integrated system design, which has the intent of facilitating high levels of effectiveness in sociotechnical systems by promoting their capacity for adaptation. Building on earlier ideas and empirical observations, this approach recognizes that to create adaptive systems it is necessary to integrate the design of all of the system elements, including the interfaces, teams, training, and automation, such that workers are supported in adapting their behavior as well as their structure, or organization, in a coherent manner. Current approaches for work analysis and design are limited in regard to this fundamental objective, especially in cases when workers are confronted with unforeseen events. A suitable starting point is offered by cognitive work analysis (CWA), but while this framework can support actors in adapting their behavior, it does not necessarily accommodate adaptations in their structure. Moreover, associated design approaches generally focus on individual system elements, and those that consider multiple elements appear limited in their ability to facilitate integration, especially in the manner intended here. The proposed approach puts forward the set of possibilities for work organization in a system as the central mechanism for binding the design of its various elements, so that actors can adapt their structure as well as their behavior—in a unified fashion—to handle both familiar and novel conditions. Accordingly, this paper demonstrates how the set of possibilities for work organization in a system may be demarcated independently of the situation, through extensions of CWA, and how it may be utilized in design. This lynchpin, conceptualized in the form of a diagram of work organization possibilities (WOP), is important for preserving a system's inherent capacity for adaptation. Future research should focus on validating these concepts and establishing the feasibility of implementing them in industrial contexts.

Does scorpion bite lead to development of resistance to the effect of local anaesthetics?

A patient posted for vaginal hysterectomy was administered subarachnoid block, which failed, so was repeated in one space above. The block failed again, after waiting for 30 min. Patient gave a history of scorpion bite twice, once at the age of 17 years on her right foot and again about 8 months back. Thereafter, balanced general anaesthesia was given. On eighth post-operative day, after explaining about her possible special condition (?Resistance to local anaesthetic agents), the patient was given left median, ulnar and radial nerve blocks at the wrist and local infiltration near the anatomical snuff box. There was neither sensory nor motor block. The scorpion venom is known to affect the pumping mechanism of sodium channels in the nerve fibres, which are involved in the mechanism of action of local anaesthetic drugs, it may be responsible for the development of 'resistance' to the action of local anaesthetic agents.

Spinal anesthesia failure after local anesthetic injection into cerebrospinal fluid: a multicenter prospective analysis of its incidence and related risk factors in 1214 patients

BACKGROUND AND OBJECTIVES

Different mechanisms have been proposed to explain spinal anesthesia failure even after LA injection into the subarachnoid space. The aim of this prospective multicenter study was to assess the incidence of spinal anesthesia failure, excluding technical problems, and then to suggest independent factors leading to failure.

METHODS

Consecutive spinal anesthetic procedures performed in 21 centers were included. Exclusion criteria were contraindications to spinal anesthesia and technical difficulties. Primary end point was the calculation of failure incidence. Factors leading to spinal anesthesia failure were investigated.

RESULTS

One thousand two hundred fourteen spinals were included. Failure rate, reported by 17 of 21 centers, was 3.2% (95% confidence interval [CI], 2.2-4.2). A total failure (no sensory block) was noted in 41% of the 39 cases of failed block. Patients in the failure group were younger as compared with patients in the success group. Using backward logistic regression, factors associated with failure were the number of puncture attempts at 3 or more (odds ratio [OR], 2.86; 95% CI, 1.20-6.79) and the absence of the use of an adjuvant medication with the local anesthetic injected (OR, 2.32; 95% CI, 1.2-4.5). Age older than 70 years (OR, 0.3; 95% CI, 0.20-0.93) was associated with a decrease of failure.

CONCLUSIONS

The results of this study showed that the incidence of spinal anesthesia failure was 3.2%. The number of puncture attempts at 3 or more and the absence of adjuvant medication associated with local anesthetic were independent factors associated with the increased risk of failure. The failure of spinal anesthesia was rare in patients older than 70 years.

A randomised controlled trial of hyperbaric bupivacaine with opioids, injected as either a mixture or sequentially, for spinal anaesthesia for caesarean section

It is common practice to mix opioids with hyperbaric bupivacaine in a single syringe before intrathecal injection of the mixture. Mixing these drugs may alter the density of the hyperbaric solution, affecting the spread of local anaesthetic and opioid. Forty-eight women having elective caesarean section under spinal anaesthesia were recruited to this double-blind, randomised trial. Group M (n=24) received 2 ml of 0.5% hyperbaric bupivacaine plus morphine 100 microg plus fentanyl 15 microg, mixed in a syringe prior to administration. Group S (n=24) received 2 ml of 0.5% bupivacaine through one syringe, followed by morphine 100 microg plus fentanyl 15 microg through a separate syringe. All patients received patient-controlled intravenous morphine for 24 hours postoperatively. Block characteristics, postoperative pain scores and morphine use were noted. The patients in Group M had higher levels of sensory block to cold than those in Group S (median T2 vs. T3) (P = 0.003). Five patients in Group M and none in Group S had a block to cold > or = T1 (P = 0.02). There was no difference between groups in the incidence of hypotension, need for vasopressor or side-effects. Morphine consumption was significantly higher in group M (13.3 +/- 11.2 vs. 6.2 +/- 7.2 mg, P = 0.015). Mixing of fentanyl and morphine with hyperbaric bupivacaine results in a higher level of sensory block than sequential administration of bupivacaine then opioid and may be associated with higher postoperative opioid requirement.

Failure of subarachnoid blocks

BACKGROUND AND OBJECTIVES

Due to the discomfort caused to patients, failure of subarachnoid blocks that happen occasionally even when properly conducted be the most capable professionals have been described since Bier. However, the concept of failure and especially identification of the causes vary. The objective of this report was to identify the causes of this discomfort through a systematic review of publications with a significant number of patients.

CONTENTS

The analysis was divided in three topics: anatomy and its variations; anesthetic agent, focusing on drug selection, its solutions, and additions to achieve the most appropriate result of the proposed surgery; and the dose, discussing concentration, volume, or gravimetric dose, to obtain the most adequate result regarding the intensity of the blockade and its duration.

CONCLUSIONS

Failures are more commonly secondary to technical factors: adequate anatomic assessment, judicious choice of the needle and puncture site, care when storing the drugs, dose adequacy, and baricity, besides proper patient positioning during and after the puncture, and they all should be adequate for the surgical objective.