Original Article

Study of Failed Spinal Anesthesia Undergoing

Caesarean Section and Its Management
Pokharel A
Consultant Anaesthesiologist, Department of Anaesthesia, National Academy of Medical Sciences, Bir Hospital,
Kathmandu, Nepal

ABSTRACT
Introduction: Spinal anesthesia is most common procedure in our peripheral hospital. Failure
of spinal anesthesia is very common, which may be due to technical error or ineffective drugs. So
in peripheral setting where there are lack of adequate facility repeating spinal anesthesia is good
alternative.
Methods: A retrospective study was performed by in 1197 parturient undergoing elective
and emergency caesarean section under spinal anesthesia by same anesthesiologist and his
assistant from December 2008 to April 2011 in maternity ward in Mechi Zonal Hospital, in order
to determine the incidence of complete and partial failure of spinal anesthesia . Partial failure
is taken as a case in which patients could not move their lower limb but still felt pain sensation
at incision sites. A routine spinal technique using intrathecal 0.5% heavy bupivacaine 2.4 mL (12
mg) was administered with a 26-gauge Quincke spinal needle. Data were collected to determine
incidence of failure of spinal anesthesia and effectiveness of repeat spinal anesthesia.
Results: Total numbers of failed spinal anesthesia in first attempt were 1.5% of total cases (i.e.18
cases). Out of these, complete failure requiring repeat spinal was 17 cases and in one case block
was up to T12 spinal level in first attempt so spinal anesthesia is repeated. Out of these 18 cases,
after repeat spinal 17 (94.45%) cases were having effective block, in one case (5.55%) there was
no effect of repeat spinal anesthesia so conversion to general anesthesia was done.
Conclusion: Spinal anesthesia using bupivacaine 12 mg (2.4 ml) produces reliable anesthesia
for caesarean section. After failure of first attempt repeat dose of 9 mg (1.8 ml) showed its
effectiveness of 94.45% without extra side effects. The outcome of repeat spinal anesthesia
seems effective with no extra side effect that we can easily practice in the peripheral setting
where there is lack of general anesthesia facility as well as in central setting to avoid the sudden
disastrous effect of general anesthesia.
Key words: Parturient; caesarean section; intrathecal; spinal anesthesia; general anesthesia

INTRODUCTION is attained relatively quickly, with a >90% success rate

after 40 to 70 supervised attempts 2. Not all spinal

S pinal anesthesia has evolved greatly since its

introduction in 1899 to clinical use by August Bier.
It is the most common technique for infra umbilical
procedures. There is a demonstrable reduction in
mortality and morbidity with regional techniques1.The
level of competency in administering spinal anesthesia
Correspondence :
Dr. Abhay Pokharel, Consultant Anesthesiologist,
National Academy of Medical Sciences, Bir Hospital,
Kathmandu, Nepal. E-mail :- a_pokharel@yahoo.com
anesthesia is successful, so general anesthesia is
readily and hastily advanced. This occurs commonly
at the expense of patient choice and the benefits of
regional anaesthesia.
Failed spinal anaesthesia is loosely defined and not
addressed in the general literature. Onset of action
differs between various intrathecal anesthetic agents.
Bupivacaine is one of extensively studied and well
understood of these agents. A bupivacaine spinal

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 Study of Failed Spinal Anesthesia Undergoing Caesarean Section and Its Management.
anaesthesia is considered to have failed if anesthesia
and analgesia have not effected within 10 minutes of
successful intrathecal deposition of heavy bupivacaine
and 25 minutes for plain bupivacaine3, 4. Ropivacaine
is 50 to 60% as potent as spinal bupivacaine; and
equipotent doses of ropivacaine will have similar
recovery times as bupivacaine5.
In the training environment the incidence of failed
spinal anesthesia can be as high as 25% or 1 in 6, and
current literature however, quotes this incidence to
be in the region of 5%6. The combined spinal/epidural
technique appears to be associated with a higher
incidence of failed spinal anesthesia.6
Latency of block varies from 10 to 60 minutes and
is shorter when hyperbaric solution is used. Spread
of analgesia continues for more than 30 minutes
after plain bupivacaine7. This process is completed in
approximately 90 to 120 minutes.
Mechanism of Action after successful intrathecal
injection, the injectate undergoes three important
phases4. As CSF volume varies from 28-81ml, drugs
mixes with CSF and gets diluted in for first 1-2 minutes,
in the next 2 to 6 minutes, the injectate then diffuses
by virtue of molecular motion and is absorbed into
the nervous tissue. Concentration is thus reduced
further. The injectate is then distributed and attaches
to receptors on the nerve roots and in this manner
clinical effect is obtained. Finally, vascular absorption
and elimination through capillary bed, parenchyma
and arachnoid villi takes place.
Technical errors are common causes of failed spinals
like: drug deposition at lower spinal level than surgical
site, improper rate of injection, failure to recognize
dural puncture, needle partly inside/outside dural sac,
patient co-operation, needle in ventral epidural space
and lateral horizontal position (25%).
Chemical interactions are also contributory like:
bloody tap causes hydrolysis of ester type anesthetics
by pseudo-cholinesterase, concentration errors, loss of
potency by prolonged exposure to light, high CSF pH,
glucose causes hyperalgesia and spotty anesthesia4.
Management of failure of a spinal anesthetic is an
event of significant concern for both patient and
anesthetist even when it is immediately apparent. The
management options are limited; so, the first rule is
to expend every effort in its prevention. The onset of
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spinal anaesthesia is rapid in most patients; it can be
slow in some; so, tincture of time should always be
allowed9. If block has not developed within 15 min,
some additional maneuver is needed. Repeating the
procedure or conversion to general anaesthesia is the
only option8.
Patchy block that appears adequate in extent, but the
sensory and motor effects are incomplete, if becomes
apparent after surgery starts, the options are to use
systemic supplementation and may not be necessary
to for general anesthesia. Sedative or analgesic drugs
are usually sufficient, when patient anxiety is a major
factor. Infiltration of the wound and other tissues with
local anaesthetic by the surgeon may also be useful in
such situations.
Repeating the block, especially in response to a poor
quality block, may lead to excessive spread, so it may
be argued that a lower dose should be used to reduce
the risk of this possibility10.
Recourse to general anaesthesia8: There are many ways
in which an inadequate block might be rescued, but
there is a limit to how much discomfort or distress an
individual patient can tolerate, so general anesthesia
must also be considered.
METHODS
A retrospective study was performed in 1197 parturient
undergoing elective and emergency caesarean section
under spinal anaesthesia from December 2008 to April
2011 maternity ward in Mechi Zonal Hospital, in order
to determine the incidence of complete and partial
failure of spinal anaesthesia. As this is a Zonal Hospital
only ASA grade 1 and 2 patients undergoing elective
or emergency caesarean section were taken for
operation due lack of man power and intensive care
facility. Detail preoperative anaesthetic check-up was
done to all patients. After coming to operation theatre
all patients were preloaded with 500 ml of Ringer
Lactate. Monitor was attached and preoperative vitals
are taken. Then patients were kept in sitting position
and after all aseptic precaution 26-gauge Quincke
spinal needle was inserted at 3rd or 4th lumbar space.
After free flow of cerebrospinal fluid (CSF) 5 ml
syringe containing 2.4 ml of 0.5% heavy bupivacaine
(sensorcaine Astra-Zeneca) was attached to spinal
needle and drug was administered. The spinal needle
was manipulated until free flow of CSF was achieved.
 Study of Failed Spinal Anesthesia Undergoing Caesarean Section and Its Management.

Patients were immediately kept on supine position Spinal anaesthesia using bupivacaine 12 mg (2.4 ml)
with a wedge under the right buttock and vitals were produces reliable anaesthesia for caesarean section.
monitored. Usually effect were noted within five After failure repeat dose of 9 mg (1.8 ml) is highly
minutes, those who do not showed effectiveness in 5 effective without extra side effects. The outcome of
minutes were watched for another 5 minutes and then repeat spinal is so effective with no side effect in 10
they were tested for temperature (cold) sensation, cases (55.55%), hypotension in 4 (22.22%) cases, 1
pain at incision site and level of pain sensation block (5.55%) case both hypotension and bradycardia, 1
was and motor response by asking them to raise their (5.55%), bradycardia 1 (5.55%) cases, high spinal 1
legs. Patients who feel pain after pin prick at the site (5.55%) cases, low spinal 1 (5.55%). Among 18 cases
of incision was considered failed spinal, so spinal only 1 cases developed high spinal block, no patient
anaesthesia were repeated. Those who developed with repeat spinal developed spinal headache.
motor block of lower limb were kept on left lateral
position to repeat spinal anaesthesia and those who Table 1. Demography of failed cases
did not develop motor block was again kept on sitting Age 16-39yrs
position to repeat spinal anaesthesia. While giving Sex Female
repeat spinal, 1.8 ml (9 mg) 0.5% of heavy bupivacaine ASA 1/ASA2 805/392
Weight in kg 45-69
was taken from new ampoule and was given only after
Duration of surgery 45-85 min
free flow of CSF on aspiration. Again patients were
watched for effect of spinal to come.
Table 2. Spinal anesthesia
Effective spinal anaesthesia was ascertained when Attempts Success Failure Total
patients feel no pain at incision site and if patients felt First (2.4ml) 1179 (98.5%) 18 (1.5%) 1197
traction pain during surgery intravenous anaesthesia Second (1.8 ml) 17 (94.5%) 1 (5.5%) 18
was supplemented. Although all patients were
monitored but especial attention was given to those Table 3. Level of Block following second dose of spinal
patients who were given repeat spinal because of anesthesia
theoretical chance of more side effects like high spinal Block level No of patient
block, post-dural puncture headache. Intraoprative T1 1 (5.55%)
pulse, blood pressure every five minutes, ECG and T2 2 (11.11%)
pulse oximetry were monitored. Symptomatic T3 7 (38.88%)
management of side effect was done as shown in table T4 2 (11.11%)
T5 4 (22.2%)
- 4. After completion of surgery patients were shifted
T6 1 (5.55%)
to ward and patients were observed for PDPH, post-
T8 1 (5.55%)
operative nausea and vomiting and residual effects of
Failed 1 GA (5.55%)
spinal anaesthesia.

RESULTS Table 4. lntraoperative events

Intraoperative No. of Treatment given %
Data were collected to determine incidence of failure events cases
of spinal anaesthesia and effectiveness of repeat spinal Uneventful 10 None 55.56%
anaesthesia. Patients were all female of age group 16- Hypotension 4 Mephenteramine 22.22%
39 years. Total failures requiring repeat spinal was Bradycardia 1 Atropine 5.55%
18 cases (1.5% of total cases), among these 17 cases High spinal 1 Difficulty in 5.55%
were complete failure with no effects and in one case block breathing so bag
block was inadequate up to T12 level. Out of these 18 mask ventilation
cases, 1 case (5.55%) of repeat spinal was failed and Low spinal 1 ketamine 5.55%
converted to general anaesthesia, as there was no block supplementation
block after repeat spinal. In another one case block was Hypotension 1 Mephenteramine 5.55%
up to T8 sensory block (5.55%) even after repeat spinal Bradycardia and atropine
and then intravenous anaesthesia was supplemented.

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 Study of Failed Spinal Anesthesia Undergoing Caesarean Section and Its Management.
DISCUSSION
It is unlikely that a spinal anesthesia will work if it
has not done so within 10 minutes of deposition
(hyperbaric bupivacaine)8. Having discussed how
spinals work, the fate of the injectate and the causes
of failed spinal anesthesia, it follows that it is feasible
to repeat the injection without increased risk of
a higher dermatome spread. The Royal College of
Anaesthetists suggest that, in keeping with the
best practice, the conversion rate from neuraxial
anaesthesia to general anaesthesia should be less than
1% for elective caesarean section and less than 3% for
non-elective caesarean section12. B. L. Sng, Y. Lim, A. T.
H. Sia16 showed failure rate of 0.5% (4/800) requiring
conversion from spinal anaesthesia to general
anaesthesia is consistent with this standard. This was
despite using a 10-mg dose of heavy bupivacaine,
which is lower than doses used in other centre and
contemporary anaesthesia texts11, 13, 14. Specifically, this
dose is lower than the previous established ED95 (dose
of drug that is effective in 95% of population) of 11.2
mg of hyperbaric bupivacaine with intrathecal fentanyl
10 l micro g plus morphine 200 micro g15. In this study
12 mg of hyperbaric bupivacaine was used, which is
the dose we use in our daily practice and incidence of
failed spinal was 1.5% which is similar with The Royal
College of Anaesthetists suggestion. Repeat injection,
especially in response to a poor quality block, may
lead to excessive spread, so it may be argued that a
lower dose should be used to reduce the risk of this
possibility10, although there is no such study available
regarding the dose of the hyperbaric bupivacaine, so 9
mg of hyperbaric bupivacaine was given.
It is common practice in the United Kingdom to use
higher volumes for spinal anaesthesia and this has
happened without higher incidence of complications19.
Immediate conversion to general anaesthesia (GA) after
a single failed spinal anaesthesia can be safely avoided.
Some patients express their preference for regional
anaesthesia and such a choice must be protected.
Often the choice of regional may have been motivated
by a potentially difficult airway and sudden conversion
to GA can be disastrous. Draping for surgical sterility
has to be done only when the anesthetist is satisfied
about adequacy of the block since repositioning may
be necessary. If the block was initially not technically
difficult and the surgical procedure allows for extra
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time to redo the intrathecal injection, it should, by
all means, be repeated. In some patients, however,
there is general resistance to local anaesthetics and
a repeat successful intrathecal injection of local
anaesthetic agent produces no analgesia/anesthesia17,
18
. In the current literature19 only two attempts are
recommended since multiple punctures can inflict
nerve injury and predispose to haematoma formation.
In our peripheral set up where there is lack of adequate
facility of giving general anesthesia as well as trained
man power and also where it takes hours to reach
higher centre this study will helpful for our society for
better outcomes for mothers and newborns.
CONCLUSION
The importance of regional anesthesia over general
anesthesia cannot be over-emphasized. An attempt
to make regional anaesthesia work is a worthwhile
endeavor. It is not necessary to immediately convert
to general anesthesia if a single shot spinal anaesthetic
injection failed to produce analgesia/anesthesia. A
repeat intrathecal injection is safe to perform and
general anesthesia can be avoided.
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