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Failed spinal anaesthesia

Feb 08, 2017


Slide 1


Procedure -a series of actions that are done in a certain way or order.

SAB (subarachnoid block)- definite steps starting & end pointscomplications possible if not performed in a set way

On 24 August 1898, August Bier and his assistant Hildebrandt injected cocaine into each others subarachnoid space. However, Biers LACK of loss of sensation was omitted from the report. His FAILED SPINAL was due to equipment/ operator failure resulting in leakage of cocaine solution from the connection between the needle and syringe.

Drasner K. Spinal anaesthesia: a century of refinement, and failure is still an option. British journal of anaesthesia. 2009;102(6):729-30. Epub 2009/05/20

"Experienced professional, healthy patient, correct technique, single puncture, adequate CSF backflow, effective anesthetic agent! So, why did it failed? - Capriciousness!!" (launehaft),

that was the expression used by August Bier, referring to the wide variation in the dispersion of cocaine solutions among patients and the quality of the results observed.

One day at OT

Substandard care may be provided so often, without apparent consequence, that eventually inferior care becomes the new standard.

Farina Z, Rout C. 'But it's just a spinal': combating increasing rates of maternal death related to spinal anaesthesia. South African medical journal 2013;103(2):81-2.

Spinal anaesthesia in inexperienced hands is associated with significant maternal mortality.

Dyer RA, Reed AR, James MF. Obstetric anaesthesia in low-resource settings. Best Practice & Research Clinical Obstetrics & Gynaecology. 2010;24(3):401-12

Procedures were typically more challenging in corrected patients; 90% of all reported difficulties in this subgroup involved epidural anesthetics. Complications were reported in 3 of 103 patients. If CSF is aspirated and local anaesthetic injected but an adequate spinal block does not occur, repeated local anaesthetic injection can cause neurological damage, probably because of maldistribution of the drug in the CSF and localized nerve toxicity resulting from high concentration of local anaesthetic around a few nerve roots.Ko JY,Leffert LR.Clinical implications of neuraxial anesthesia in the parturient with scoliosis. Anaesth Analg . 2009 Dec;109(6):1930-4.

Besides the type of anaesthesia and operative urgency, other factors associated with pre-operative failure of regional anaesthesia included body mass index, no previous Caesareans, and indication for Caesarean of acute fetal distress or maternal medical condition. Inadequacy of pre-operative anaesthetic block and duration of surgery were important risk factors for intra-operative failure. For spinal anaesthesia, use of a spinal opioid was associated with less pre-operative failure.

Kinsella SM.A prospective audit of regional anaesthesia failure in 5080 Caesarean sections. Anaesthesia.2008 Aug;63(8):822-32.

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.

R. Fuzier, B. Bataille, V. Fuzier, A.S. Richez.Spinal anesthesia failure after local anesthetic injection into cerebrospinal fluid: a multicenter prospective analysis of its incidence and related risk factors in 1214 patients.Reg Anesth Pain Med, 36 (4) (2011), pp. 322326

Tolerance and resistance to local anesthetic drugs are translated to the body as delay in the onset, decrease in the duration of spinal anesthesia or even complete failure of response to the usual dose of the local anesthetic, thus needing to increase the dose of local anesthetic to overcome the state of tolerance.

Maha M.I. Youssef,Hala Ezzat Abdelnaim. Failed spinal anesthesia in addicts: Is it an incidence or coincidence? Egyptian Journal of Anaesthesia.Volume 30, Issue 3, July 2014, Pages 247253

Marfan's syndrome: known to cause dural sac ectasia in 6392% of affected adults.Dural sac ectasia can lead to inadequacy of spinal anaesthesiadue to the increased volume of the caudal dural sac.

Clayton, R.; Robinson, C. Inadequate neuraxial anaesthesia in Marfan's syndrome:European Journal of Anaesthesiology:June 2013 - Volume 30 - Issue - p 129129

More than one scorpion bites and more recent bites are associated with failure of the spinal block rather than inadequate spinal block.

Mridul M Panditrao, Minnu M Panditrao. Effect of previous scorpion bite(s) on the action of intrathecal bupivacaine: A case control study. Indian Journal of Anaesthesia, Vol. 57, No. 3, May-June, 2013, pp. 236-240

Absent CSF or dry tap is the only cause of failure that is immediately obvious. Causes of "dry tap" include a blocked needle, needle in the wrong space, post-spinal surgery and low CSF pressures. It is also possible that in patients with "absent" CSF or very low CSF pressure, the subarachnoid space is obliterated as the arachnoid "collapses" on the pia.

Ghatak T, Gurjar M, Kohat AK .Dry spinal tap due to primary psoas and paraspinal abscesses., Anaesth.2013Apr;7(2):215-6 Tsui BC,Wagner AM,Cunningham K.Threshold current of an insulated needle in the intrathecal space in pediatric patients. Anesth Analg2005 Mar;100(3):662-5

Sequelae of one error

Wrong site, wrong method

Proper dose( vol., concn.) Actual dose chosen will depend on the specific local anaesthetic used, the baricity of that solution, the patients subsequent posture, the type of block intended, and the anticipated duration of surgery.

Thus, knowledge of the factors influencing intrathecal drug spread and clinical experience with any particular local anaesthetic preparation are important guides to choosing an effective dose.

Proper dose( vol., concn.)

Carvalho B et al stated that although the lowest possible dose of bupivacaine is recommended to minimise side effects such as maternal hypotension, nausea, shivering and prolonged stay in the PACU (post anaesthetic care unit), this reduced dose was also associated with intraoperative pain and failure of block in prolonged surgery.

Carvalho B, Cohen SE, Lipman SS, Fuller A, Mathusamy AD, Macario A. Patient preferences for anesthesia outcomes associated with cesarean delivery. Anesthesia and analgesia. 2005;101(4):1182-7

Proper dose( vol., concn.)

It becomes even more important to ensure that the whole of that lower dose reaches the CSF and then spreads properly, remembering that the dead space of the needle will contain a significant pro-portion of what is a small volume to start with.

Failure after perfect injection

Extradural cysts such as Tarlovs, arachnoid and dermoid cysts, and cystic neuromas.

Although they contain CSF, communication with the intrathecal space may be absent, allowing free flow of CSF but not allowing injected local anaesthetic to reach the cauda equina and thus preventing anaesthesia.

Tarlov or perineural cysts

Tarlov or perineural cysts

Extradural meningeal dilatationsEncase posterior spinal nerve root sheathsMainly lumbosacralIdiopathic, post-trauma or surgeryRadicular painNarrow neck in continuity with CSFCurrent adult incidence estimated 4.59%

Identification of fluid aspirateIntradermal cyst (most commonly sebaceous cysts from hair follicles)Lipaceous material, discernible click on cyst puncture, no free flow of fluidMay contain keratin particles

Kell, Gudin, Brull. J Clin Anaesth 1996;8;603604

Failure after perfect injection

Intrathecal sac

Trabeculae in subarachnoid space

Presence of a subdural space

Injection into epidural space

Patchy spinal block is a rare occurrence. Sun (1) reported a similar event in a patient who had had three previous spinal operations. The spread of local anesthetic could be impeded by a herniated disk, as in our patient, or by septa within the intrathecal space (2).

1. Sun KO. Spinal anaesthesia following previous spinal surgery. Eur J Anaesthesiol 1994;11:3213.2. Armstrong PJ. Unilateral subarachnoid anaesthesia. Anaesthesia 1989;44:9189.Suren, Mustafa MD; Patchy Spinal Anesthesia .Anesthesia & Analgesia: April 2006 - Volume 102 - Issue 4 - p 1290

Failure after perfect injection Possible positions of the tip of a pencil-point needle

Failure after perfect injection The dura/arachnoid may also act as a flap valve, allowing CSF to be aspirated but on injection causing it to be displaced.

More obvious causes of misplaced injectate are failure to secure the syringe into the hub of the needle and allowing a small amount, but large percentage, of local anaesthetic to be lost. The chances of this can be minimised by firmly securing the syringe to the hub. This however can cause movement of the needle giving rise to another cause of injectate loss.

Although the more modern amide-linked drugs(e.g. lidocaine, bupivacaine, etc.) are much more stableand can be heat sterilized in solution and then stored forseveral years without loss of potency, there have been anumber of reports attributing failure of spinal anaesthetics to inactive drug.

Wood M, Ismail F. Inadequate spinal anaesthesia with 0.5%Marcaine Heavy (batch 1961).Int J Obstet Anaesth2003;12: 310 1

Failure after perfect injection

Rarely, however, the clear fluid is not CSF, but local anaesthetic injected as a top-up for an epidural which then proved inadequate for a Caesarean section, o