Spinal anaesthesia for caesarean section following epidural analgesia in labour: a relative contraindication

Gupta, Anil; Enlund, Gunnar; Bengtsson, Mats; Sjöberg, Fei

doi:10.1016/0959-289x(94)90229-1

Cited by 31 publications

(13 citation statements)

References 17 publications

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“…[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. 25 Leakage of local anesthetic from the epidural to the subarachnoid space and cephalad displacement of local anesthetic in the cerebrospinal fluid by epidurally injected fluid have both been implicated as causes for higher spinal block.…”

Section: Discussionmentioning

confidence: 99%

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

Visser

Dijkstra

Albayrak

et al. 2009

Can J Anesth/J Can Anesth

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Purpose Failed conversion of epidural labor analgesia (ELA) to epidural surgical anesthesia (ESA) for intrapartum Cesarean delivery (CD) has been observed in clinical practice. However, spinal anesthesia (SA) in parturients experiencing failed conversion of ELA to ESA has been associated with an increased incidence of serious side effects. In this retrospective cohort analysis, we examined our routine clinical practice of removing the in situ epidural, rather than attempting to convert to ESA, prior to administering SA for intrapartum CD. Methods Hemodynamic data, frequencies of either high or total spinal block, and maternal and neonatal outcome data were gathered from the anesthesia records of all parturients at the Amphia Hospital, undergoing intrapartum CD between January 1, 2001 and May 1, 2005. Results Complete data were available for 693 patients (97.6%) of the 710 medical records that were identified. Of the 693 patients, 508 (73.3%) had no ELA and received SA, 128 patients (18.5%) received SA following epidural anesthesia for labor, 19 (2.7%) underwent conversion of ELA to ESA, and 38 (5.5%) received general anesthesia. When comparing both SA groups, no clinically relevant differences were observed regarding the incidence of total spinal block (0% in both groups) or high spinal block (0.2 vs 0.8%, P = 0.36). The number of hypotensive episodes, the total amount of ephedrine administered, and the Apgar scores recorded at 5 and 10 min were similar amongst groups. Conclusions The incidence of serious side effects associated with SA for intrapartum CD following ELA is low and not different compared to SA only. RésuméObjectif Dans la pratique clinique, l'e´chec du passage d'une analge´sie pe´ridurale pour le travail obste´trical a`une anesthe´sie pe´ridurale chirurgicale pour un accouchement par ce´sarienne a e´te´observe´. Cependant, la rachianesthe´sie re´alise´e chez les parturientes chez qui la conversion de la pe´ridurale avait e´choue´a e´te´associe´e à une incidence accrue d'effets secondaires graves. Dans cette analyse de cohorte re´trospective, nous avons examineń otre pratique clinique habituelle, qui consistait a`retirer le cathe´ter pe´ridural avant de re´aliser une rachianesthe´sie pour un accouchement par ce´sarienne, plutôt que de tenter une conversion de la pe´ridurale.

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Section: Discussionmentioning

confidence: 99%

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

Visser

Dijkstra

Albayrak

et al. 2009

Can J Anesth/J Can Anesth

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“…However, spinal anesthesia after suboptimal labor epidural analgesia has been associated with high blocks necessitating general anesthesia and intubation. [1][2][3][4][5][6][7] Rapid sequence induction in the face of a rapidly developing high block can be hazardous and complicated by aspiration and failed intubation.…”

Section: Discussionmentioning

confidence: 99%

“…Gupta et al reported three cases with high spinal blocks following inadequate epidural analgesia in the absence of an epidural bolus. 6 Patients in their series had received epidural infusions before a full-dose subarachnoid block.…”

Section: Discussionmentioning

confidence: 99%

“…To avoid general anesthesia in these situations given the increased risk of maternal morbidity and mortality, some anesthesiologists have administered spinal anesthesia but have reported high blocks. [1][2][3][4][5][6][7] The advantages of regional anesthesia in this situation may thus be negated if a high block results in conversion to general anesthesia.…”

Section: Introductionmentioning

confidence: 95%

See 1 more Smart Citation

Spinal anesthesia for cesarean section following inadequate labor epidural analgesia: a retrospective audit

Dadarkar

Philip

Weidner

et al. 2004

International Journal of Obstetric Anesthesia

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“…Many consider spinal anesthesia as contraindicated following an ongoing or failed epidural because of the potential risk of total spinal block [1][2][3][4], the incidence of which was estimated to be 11% versus 0.02% in patients undergoing spinal anesthesia alone [4].The manifestations of a total spinal block occur within minutes of injecting a spinal drug, and may include profound hypotension, apnea, loss of consciousness, and even cardiac arrest. In our patient, hypotension did not supervene because of the phenylephrine infusion, thus avoiding a serious cardiac compromise in the presence of total spinal anesthesia.…”

Section: To the Editormentioning

confidence: 98%

Total spinal block after spinal anesthesia following ongoing epidural analgesia for cesarean delivery

2011

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A 26-year-old woman in labor requested an epidural analgesia. The epidural space was located at 5 cm, and the catheter was threaded 4 cm. After 12 h of labor, the patient was scheduled for cesarean delivery for failure to progress. A level to pinprick at T12 was elicited, and the catheter was noted to be at 7 cm from the skin. Based on its inadequate distance in the epidural space, the catheter was removed and spinal anesthesia with bupivacaine 10.5 mg was performed. Immediately thereafter, phenylephrine infusion was started at a rate of 100 lg/min. The last bolus of bupivacaine 0.25% 5 ml was administered 90 min before spinal anesthesia. After supine positioning with left uterine displacement, level to pinprick was at T6. Patient's blood pressure was 120/80, heart rate 90 bpm, and SpO 2 100%. Ten minutes after the subarachnoid injection, the patient developed panic and started complaining of difficulty in breathing, followed by respiratory arrest and loss of consciousness. She was immediately intubated with no requirement for any medication. Positive pressure ventilation was initiated, and anesthesia was maintained with nitrous oxide and sevoflurane. A baby was delivered 20 min after subarachnoid injection with good Apgar scores. During the entire episode, there was no change in the patient's vital signs, with no need for any additional vasopressors except for the continuous phenylephrine infusion. One hour later, the patient was awakened and extubated with no further complication.Many consider spinal anesthesia as contraindicated following an ongoing or failed epidural because of the potential risk of total spinal block [1-4], the incidence of which was estimated to be 11% versus 0.02% in patients undergoing spinal anesthesia alone [4].The manifestations of a total spinal block occur within minutes of injecting a spinal drug, and may include profound hypotension, apnea, loss of consciousness, and even cardiac arrest. In our patient, hypotension did not supervene because of the phenylephrine infusion, thus avoiding a serious cardiac compromise in the presence of total spinal anesthesia.Our case shows that spinal-induced hypotension with the resulting hypoperfusion of the brain and brainstem is not the only cause of respiratory failure and loss of consciousness. These sequelae were probably caused by the cephalad spread of intrathecal drugs resulting from compression on the dural sac by the epidural solution, with the local anesthetics interfering with the neuronal function in the cervical spinal cord and above.To minimize this complication, it was recommended to avoid epidural boluses in the 30 min preceding spinal injection, to reduce the spinal dose, and to delay supine positioning following spinal injection [5]. For our patient, no boluses were administered in the 90 min before spinal, bupivacaine dose was reduced (10.5 mg instead of 12.75 mg), and she still developed total spinal block requiring tracheal intubation.In conclusion, total spinal block after spinal anesthesia for cesarean delivery following ongo...

show abstract

Spinal anaesthesia for caesarean section following epidural analgesia in labour: a relative contraindication

Cited by 31 publications

References 17 publications

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

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

Spinal anesthesia for cesarean section following inadequate labor epidural analgesia: a retrospective audit

Total spinal block after spinal anesthesia following ongoing epidural analgesia for cesarean delivery

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