Total Spinal Anesthesia a case report

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Total Spinal AnesthesiaFollowing Subarachnoid
Injection of Local Anesthetic for Cesarean
Section(Two Case Reports)

• Dmitry Portnoy, MD
• Anesthesiology Department

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Case 1. Preoperative Assessment

• 21 y/o, G1, at 41 weeks induced for postdates,
  suspected chorioamnionitis.
• No previous medical or surgical history.
• System review was unrevealing, NKDA
• PE unremarkable, Wt-76 kg, Ht-53
• VS BP-99/54, HR-82, RR-20, low FHR baseline
• AW MP-I, TMD - 6 cm, neck - FROM, mouth opening
  - 4.5 cm.

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Timeline

• 1740 Active labor, Cx - 7 cm. CSE immediate
  pain relief.
• 2025 LEA activated after negative standard test
  dose.
• 0145 Called for c/s(failure to descend) Pump
  off Pt reported some right-sided pain.
  LEC pulled back 1 cm.
• 0155 LEA activated with total of 15 cc of 3
  chloroprocaine. Sensory
  block remains considerably inadequate on right
  side.
• 0210 To OR LEC removed intact SAH done at
  L2-L3, sitting with 1.2 cc(9,0 mg) of 0.75 Bup
  25 mcg Fentanyl Epi
• 0214 Total spinal developed. EZ ventilation with
  cricoid pressure. Uneventful tracheal intubation
  following 250 mg of STP.
• 0234 Baby delivered without incident with Apgar 8
  and 9.
• 0310 Extubated awake, in full strength, with
  airway reflexes intact.
• 0320 To PACU, VSS, sensory block at T3.
• POD 2 Discharged home in good condition.

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Spinal Following Epidural Controversy

• J.H.Waters compared epidural/spinal and spinal
  alone ( Anesthesia and Analgesia,1994781029-35).
  
• Similar sensory level in both groups
• 20 less dose and volume in epidural/spinal
  group
• high spinal in 1 of 17 in epidural/spinal group
• spinal anesthesia can be performed safely after
  inadequate epidural anesthetic

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Spinal Following Epidural Controversy

• T.Adams reported 61 cases of failed epidurals
  converted to spinal anesthesia(Anesth
  Analg199581654-6)
• Standard dose of 0.75 hyperbaric bupivacaine
  used
• No high block or other complications noted
• Kestin IG. Spinal anaesthesia in obstetrics. (
  British Journal of Anaesthesia 199166596-607)
• spinal technique may be used if an extradural
  block is inadequate after giving the maximum dose
  of local anesthetic

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Spinal Following Epidural Recommendations

• Caution is required in the presence of any fluid
  in extradural space( volume and time dependant).
• Reduction of spinal anesthetic dose/volume by
  20.
• Special considerations for patients with
  suspected difficult airway
• All patients who undergo RA warrant precautions
  for possible need of general anesthesia
• Catheter based intermittent technique
• Elective secure of the airway

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Case 2. Preoperative Assessment
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Factors Influencing Distribution of Local
Anesthetic Solutions (based on Dr. N. Greens
review)

• Patient characteristics
• Technique of injection
• Characteristics of spinal fluids
• Characteristics of anesthetic solution
• Vasoconstrictors
• Diffusion characteristics

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Patient characteristics

• Age
• Height
• Gender
• Intraabdominal pressure
• Anatomical configuration of spinal column
• Position

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Technique of injection

• Site of injection
• Direction of needle
• Direction of bevel
• Rate of injection
• Barbotage

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Characteristics of anesthetic solution

• Density ( vs specific gravity vs baricity)
• Amount of anesthetic
• Concentration of anesthetic
• Volume of injected anesthetic
• Presence of vasoconstrictors

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Characteristics of spinal fluids

• Composition
• Circulation
• Volume
• Pressure
• Density

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Factors of great clinical significance

• Baricity of anesthetic solution.
• The dosage of anesthetic solution.
• The position of the patient (with hypo- or
  hyperbaric solutions)

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Demonstrable factors of varying clinical
significance

• Patient age
• Patient height
• Anatomical configuration of spinal column
• The direction of the needle during injection
• The volume and density of CSF
• The volume of anesthetic solution

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Dosage of Spinal Anesthetic and Patients
Variables in the Term Parturient

• Isobaric versus hyperbaric solutions.
• Standard versus variable dosage.
• No evidence that one way is better than another.
• No golden standard dose is known dosages from
  7.5 mg to 15.0 mg were successfully used.

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Dosage of Spinal Anesthetic and Patients
Variables in the Term Parturient(Dr. Ezzat
I.Abouleish table)
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Dosage of Spinal Anesthetic and Patients
Variables in the Term Parturient

• Dr. R.Vadheras recommendations for spinal
  hyperbaric bupivacaine injections

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Dosage of Spinal Anesthetic and Patients
Variables in the Term Parturient

• Mark C. Norris, M.D., Anesthesiology
  72478-482,1990

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Dosage of Spinal Anesthetic and Patients
Variables in the Term Parturient

• Mark Norris, M.D., Anesth Analg, 198867555-8
• Standard technique
• 50 term parturients
• 12 mg of hyperbaric bupivacaine
• Lateral decubitus position

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Dosage of Spinal Anesthetic and Patients
Variables in the Term ParturientDr. M. Norris
study conclusion

• Patients Variables
• Age (20 42)
• Height (146 175 cm / 411 60)
• Weight (55 136 kg)
• Body mass index (19 50 kg/m2)
• Did not correlate with the spread of sensory
  blockade
• It is not necessary to vary the dose of injected
  hyperbaric bupivacaine

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Vertebral Column Length Variability and Spread of
Hyperbaric Spinal Anesthetic

• B.Hartwell study significant correlation exist

• M. Norris study no clinically significant
  correlation

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General Recommendations

• The incidence of high spinal block in obstetric
  anesthesia is probably higher.
• Careful monitoring of sensory level is advisable,
  particularly in patients with extreme variables.
• Be fully prepare to manage airway of any patient
  that undergo spinal anesthesia.
• Take special consideration for patients with
  potential difficult airway.