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Vipin kumar FAILED SPINAL ANAESTHESIA
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Failed spinal anaesthesia

Feb 08, 2017

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Page 1: Failed spinal anaesthesia

Vipin kumar dhama

FAILED SPINAL ANAESTHESIA

Page 2: Failed spinal anaesthesia

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

SAB (subarachnoid block)- definite steps starting & end points complications possible if not performed in a

set way

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On 24 August 1898, August Bier and his assistant Hildebrandt injected cocaine into each other’s subarachnoid space. However, Bier’s 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

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"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.

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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.

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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

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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.

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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.

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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. 322–326

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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 247–253

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Marfan's syndrome: known to cause dural sac ectasia in 63‐92% of affected adults.Dural sac ectasia can lead to inadequacy of spinal anaesthesia due 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 129–129

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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

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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. 2013 Apr;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

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Sequelae of one error

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Wrong site, wrong method

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Proper dose( vol., concn.) Actual dose chosen will depend on the specific local

anaesthetic used, the baricity of that solution, the patient’s 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.

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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

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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.

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Failure after perfect injection

Extradural cysts such as Tarlov’s, 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.

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Tarlov or perineural cysts

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Tarlov or perineural cysts

Extradural meningeal dilatations Encase posterior spinal nerve root sheaths Mainly lumbosacral Idiopathic, post-trauma or surgery Radicular pain Narrow neck in continuity with CSF Current adult incidence estimated 4.5–9%

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Identification of fluid aspirate Intradermal cyst (most commonly sebaceous cysts

from hair follicles) Lipaceous material, discernible click on cyst puncture,

no free flow of fluid May contain keratin particles

Kell, Gudin, Brull. J Clin Anaesth 1996;8;603–604

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Failure after perfect injection

Intrathecal sac

Trabeculae in subarachnoid space

Presence of a subdural space

Injection into epidural space

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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;11:321–3.

2. Armstrong PJ. Unilateral subarachnoid anaesthesia. Anaesthesia 1989;44:918–9.

Suren, Mustafa MD; Patchy Spinal Anesthesia .Anesthesia & Analgesia: April 2006 - Volume 102 - Issue 4 - p 1290

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

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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.

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 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.

 

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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

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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, or even spreading there from the lumbar plexus.

Lang SA, Prusinkiewicz C, Tsui BCH. Failed spinal anesthesiaafter a psoas compartment block.Can J Anesth2005;52:74–8

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Unfortunately, a positive test for glucose in the fluid doesnot confirm that this fluid is definitely CSF because extra-cellular fluid constituents diffuse rapidly into fluids injected into the epidural space.

Stace JD, Gaylard DG. Failed spinal anaesthesia.Anaesthesia1996;51: 892 – 3

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failure

partial

height

quality

complete

duration

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Height- sensory, motor block.

Quality- pt. cooperation, comfort

Duration- drug solution, dose, baricity , position etc.

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Russell IF. At caesarean section under regional anaesthesia, it is essential to test sensory block with light touch before allowing surgery to start. International Journal of Obstetric Anesthesia. 2006;15(4):294-7.

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Complete failure

Complete absence of sensory or motor block.

Despite waiting “long enough” for the block to develop.

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Most complications after SAB are due to autonomic blockade while surgery is made possible due to sensory , motor blockade.

So , adequate monitoring must even after completely ineffective sensorimotor nerve block.

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Waiting for effect

Most clinicians wait for 15 minutes .

Gupta A et al observed time to achieve maximum cephalad spread to be within 10 minutes in spinal anaesthesia with 0.5% 2 ml hyperbaric bupivacaine.

Gupta A, Kaur S, Khetarpal R, Kaur H. Evaluation of spinal and epidural anaesthesia for day care surgery in lower limb and inguinoscrotal region. J Anaesthesiol Clin Pharmacol 2011;27:62-6

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.

Neurologically, paralysis of the legs merely indicates that there is sufficient local anaesthetic within the lumbar spinal canal to block the motor nerves to the legs, but gives no indication of how dense the block might be at higher thoracic levels.

I. F. Russell . A comparison of cold, pinprick and touch for assessing the level of spinal block at caesarean sectionInternational Journal of Obstetric Anesthesia (2004) 13, 146–152

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Repeat spinal ???

The differential of a truly failed single-injection spinal anesthetic may include a large thecal volume, dural ectasias, cysts, and simple anatomic sacral restriction.

To minimize maldistribution and neurotoxicity, the sum dose of all intrathecal local anesthetics administered for a single procedure should not significantly exceed the maximum recommended single-dose amount.

Joan E. Spiegel Philip Hess. Large intrathecal volume: a cause of true failed spinal anesthesia.Clinical Reports Journal of Anesthesia. August 2007, Volume 21, Issue 3,pp 399-402

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Repeat spinal ???

A repeat injection of local anesthetic could lead to excess spinal blockade and possibly cause high or total spinal anesthesia. The alternatives include general anesthesia, peripheral nerve blockade, or infiltration of local anesthesia at the surgical site by the surgeon along with sedation.. It is important to think through what will be best for the patient before choosing another plan of action.

www.nysora.com

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Barriers to spread within the subarachnoid space may also affect epidural spread (and vice versa), so an attempt at epidural block may not succeed either.

The final concern, particularly applicable to the last mentioned, but relevant to nearly all situations where a repeat block might be considered, is that the adjacent nerve tissue is already affected by local anaesthetic action so that the risk of direct needle trauma is increased.

P. D. W. Fettes,J.-R. Jansson J. A. W. Wildsmith. Failed spinal anaesthesia: mechanisms, management, and Prevention.Br J Anaesth. 2009;102(6): 739–48

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The Royal College of Anaesthetists (RCOA) suggest that, in keeping with the best practice, the conversion rate from spinal anaesthesia to general anaesthesia should be less than 1% for elective caesarean section and less than 3% for non-elective caesarean section.

 Kinsella M ea. Royal College of Anaesthetists | Raising the Standard: a compendium of audit recipes | 3rd Edition. 2012.

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Factors affecting drug spread

The level of Injection The volume of drug Patient position Speed of Injection

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Management ( for residents)

Pre procedure – check for difficulty , pt. comfort & cooperation , plan accordingly.

Make sure that the patient is in the correct position and that the correct angles and insertion technique are used.

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Management ( for residents)

Check spinal needle, can remove stylet & check tip.

Check LA , adjuvants .

Keep spinal tray separate from other drugs.

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Management ( for residents)

Pt. position for spinal should be optimum.

Use same brand of needle, syringe for initial learning.

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PROTOCOL FOR SAB (deptt of anaesthesia, llrm medical college)

At the time of PAC, absolute/ relative contraindications to SAB to be kept in mind. Consent to be taken.

Minimal monitoring required – NIBP, SpO2, PR. ECG is preferred.

Give calculated replacement fluid/preloading, preferably crystalloid, depending upon patient status, weather (more in summers)

Compare reading of monitored parameters (NIBP, PR) with baseline values. Consult with your senior if any discrepancy present (more than 20% variation ).

Prepared spinal tray – Flat, horizontal tray (covered with sterile cloth). Place 5 gauze pieces, gloves (of app. Size), cut sheet, gown, bowls for sterilizing agents, sponge holding forcep. Keep minimal distance between patient back and spinal tray. Keep syringe, spinal needle away from sterilizing agents.

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Position of patient – sitting position preferred. Place a stool beneath patient feet or extend patient legs on O.T. table.

Expose patient back from base of scapula to gluteal region. Ensure both shoulders and iliac crests are at same level.

SpO2, PR are to be continuously monitored. Scrub hands as per instructions. (first wash in morning to be standard protocol ) Wear apron after drying hands using a sterile towel. Wear cap & mask while doing procedure. No coughing or sneezing at patient back. Use either 2% chlorhexidine + 70% alcohol or 10% iodine solution + 70% alcohol for

sterilizing the skin. Min. contact time for iodine solution – 2 min,. Min. contact time for alcohol – 30 sec. After proper time, clean sterilizing agent using gauze piece. Can allow alcohol to air

dry. During contact time, place cut- sheet over patient back, load drug solution, open

spinal needle. Don’t take spinal needle out from plastic cover. Use filter needle for loading the drug solution. After painting & draping the part, assess the proper interspace,

palpate both iliac crests to ensure they are in same plane. Now ask the patient, to make the optimum position for SAB.

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Local anaesthetic infiltration at the puncture site must include both intradermal and s.c. injection.

Take out the spinal needle from its cover, donot touch the anterior portion of needle. Insert needle till it is fixed in ligaments, i.e. needle doesnot sway when you remove your hands. When fixed, use your non dominant hand to insert needle further.Go slow to feel for piercing

the dura mater. After removing stylet, place dorsal side of non dominant hand on pt. back,

hold hub of needle using thumb & index finger.(preferred) CSF flow should be clear, appropriate for needle size. Allow 1-2 drops of CSF

to fall before attaching syringe.( in a rotator motion keeping marking of syringe upwards).

Rotation of the needle through 180° after the initial appearance of CSF can be done.

Aspirate 0.2- 0.3 ml CSF into syringe ,see increase in volume , oily flow from above. Inj. Rate – 0.2 ml/sec.

In case of any doubt, remove syringe , reassess flow. Observe for any resistance to injection/ paraesthesias/ pt. movement during

drug injection/ any other deviation from normal proceedings. Act according to situation. Don’t inject drug any further.

Withdraw needle in one smooth, gentle fashion using non dominant hand (preferred).

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documentation table after SAB

Time Sensory block

Motor block

Hemodynamics( normal range)

Tests( cold/ deep pressure etc.)

0 2 min. 3 min. 10 min

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Poor quality of effect may be due to other factors ( SAB is simply blockade of sodium channels in spinal nerves with LA). Other central/ peripheral sensations can result in apparent inadequate effect

Analgesic sedation is commonly given intraop. , depending on clinical judgement.

Causes – other drugs / peritoneal handling/ cough /retching /psychiatric disorders etc.

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In 1907, Alfred E. Barker wrote that for successful spinal analgesia it is necessary ‘to enter the lumbar dural sac effectually with the point of the needle, and to discharge through this, all the contemplated dose of the drug, directly and freely into the cerebrospinal fluid, below the termination of the cord’ .Failure to follow the details of this advice is the commonest cause of a poor result.

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