Failed extradural anaesthesia for Caesarean section. Complication of subsequent spinal block

Abstract

SummaryTwo cases of unexpected high spinal anaesthesia following failed extradural anaesthesia for Caesarean section are described. In both cases rapid and unexpected advance of blockade, after the subarachnoid injection of moderate doses of local anaesthetic, required tracheal intubation. In one of the cases 15 ml of 0.9% saline, but no local anaesthetic. had been injected into the extradural space, suggesting that the mechanism involved is the cephalad displacement of the cerebrospinal fluid by extradural fluid, and not leakage of extradural anaesthetic solution into the subarachnoid space. Key wordsAnaesthetic techniques, regional; spinal, extradural. Complications.Extradural anaesthesia is a popular technique for Caesarean section in the United Kingdom. Inadequate analgesia occurs in about 50% of women undergoing Caesarean section under extradural block with 0.5% bupivacaine [ 1-31. Usually, supplementation with inhalational, systemic or local analgesia is adequate. However, in some cases of failed extradural blockade, further regional or general anaesthesia may be required.In the two patients described below, spinal anaesthesia was performed following failure to establish adequate extradural anaesthesia for Caesarean section. In both excessive spinal blockade required tracheal intubation. Case histories Case IA 19-year-old primigravida (weight 52.6 kg, height 150 cm) was admitted for induction of labour with poor weight gain (2.6 kg) and postdates (term + 7 days). Artifical rupture of membranes was performed and an intravenous infusion of oxytocin started.Three hours after induction of labour, the patient requested extradural analgesia. The extradural was sited at L213 interspace, with the patient in a sitting position, using the loss of resistance to air technique. The extradural space was identified at 4 cm, and 3 cm of catheter was introduced into the space. Following an uneventful test dose (4 ml of 2% lignocaine), 8 ml of 0.25% bupivacaine was given. This produced a bilateral sensory block to T,.Two hours after siting the extradural, vaginal examination revealed a hand presentation and, it was decided to proceed to Caesarean section. The patient requested to remain awake, so 10ml of 0.5% bupivacaine was given through the extradural catheter.After a further 10 min, the sensory block only extended to T,,, so a further dose of 10 ml of 0.5% bupivacaine was given. After a further 20 min the block had still not extended above T,,, and as the patient still wanted to stay awake, a spinal block was performed. The patient was positioned in the right lateral position, routine lumbar puncture at the L3,4 interspace was performed with a 26-gauge needle, and 2.0ml of 0.5% bupivacaine with 8% glucose was injected into the cerebrospinal fluid. The patient was returned to the supine position with a wedge under the right hip. Four litres per minute of oxygen was administered by face mask. Within 5 min the block extended to T,, and the Caesarean section was started. The patient's arterial pressure decreased to 70/40 mmH...

Spinal anesthesia for intrapartum Cesarean delivery following epidural labor analgesia: a retrospective cohort study

“…1,10 However, in anecdotal reports on SA following failed epidural anesthesia for intrapartum CD, concerns were raised that this technique may result in a higher incidence of high or total spinal block. [3][4][5][6][7][8] Also, a series of three patients with high spinal blocks after continuous ELA without top-up doses (comparable with our SA group) has been reported. 23 In contrast, SA has been safely used for intrapartum CD in patients with failed epidural anesthesia after epidural infusions with or without top-up dosing, 2,24 and in patients selected because of inadequate labor epidural analgesia.…”

“…1 However, the efficacy of epidural anesthesia has been reported as inferior to that of SA in both elective and emergency situations. 1,2 Although it has been associated with a high incidence of deleterious effects, such as high-level or total spinal block, respiratory insufficiency, and hypotension [3][4][5][6][7][8] an increased use of SA for intrapartum CD following epidural labor analgesia (ELA) has been observed. 2,9 In our practice, patients who present for intrapartum CD, after receiving an epidural catheter for pain relief during labor, routinely receive SA after the epidural catheter is removed without an attempt to administer local anesthetic to convert ELA to epidural surgical anesthesia (ESA).…”

A comparison of spinal and epidural anesthesia for cesarean section following epidural labor analgesia: A retrospective cohort study

“…4,18 A retrospective cohort study by Visser et al 6 concluded that the incidence of serious side effects associated with SA for cesarean delivery following epidural labor analgesia is low and no different than that with SA only. Dadarkar et al 19 also suggested some methods to avoid high blocks, including avoiding epidural boluses immediately preceding spinal injection, using a lower spinal dose, and delaying supine positioning following spinal injection.…”

Spinal anesthesia using a continuous spinal catheter for cesarean section in a parturient with prior surgical correction of scoliosis

“…If spinal anesthesia is performed after the epidural administration of anesthetic, it is possible that the solution administered into the epidural space squeezes the dura mater and cerebrospinal fluid (CFS), resulting in the excessive cephalad spread of the intrathecal anesthetic agent [10]. Previous articles reported that the unexpectedly rapid cephalad spread of a spinal block necessitated respiratory support under tracheal intubation [11,12]. Therefore, we felt that the first choice for the patient with spinal instrumentation was titrated spinal anesthesia, to avoid this unexpected cephalad spread.…”