Failed Spinal in LSCS: GA

as rescue
Dr Shelly Rana
DRPGMC Kangra
What Constitutes Failed Spinal?

Failure to provide satisfactory surgical conditions

and/or maternal comfort and satisfaction during
caesarean section with or without conversion to
general anaesthesia.

Parikh KS, Seetharamaiah S. Approach to failed spinal anaesthesia for caesarean section. Indian
J Anaesth 2018;62:691-7.
 Incidence of failed spinal?
Various studies have quoted failure rate up to
17%

With careful performance of technique, a failure rate

as low as 1% is attainable.

Sng BL, Lim Y, Sia AT. An observational prospective cohort study of incidence and
characteristics of failed spinal anaesthesia for caesarean section. Int J Obstet
Anesth 2009;18:237‑41.
Management options ; 3Rs?

Repeat block

Urgent, Category 1
Revive block Caesarean section

Recourse to general Revival fails

anaesthesia Parturient request
“Failed Spinal” Algorithm
Conversion rate to GA?

The conversion rate from spinal to general anaesthesia

should be <1% in elective
and
<3% in emergency caesarean section

Kinsella M. Raising the Standard: A Compendium of Audit Recipes.

London: The Royal College of Anesthetists; 2012.
Approximately 218,285 CD cases were
identified between 2010 and 2015.

GA was used in 5.8% of all

CDs and 14.6% of emergent
CDs.
Does ↑Airway Risk Exist in OB Population

• Incidence of difficult intubation o 1-6% in OB population

o 1.5-8.5% in general population
[CL grade3/4]

• Incidence of failed intubation o 0.13 -0.6% OB population

o 0.13-0.3% general population
Does a trainee in the obstetric unit still get anxious
when they hear “ she needs GA”

• GA rate 7%
• Emergent caesarean
delivery (57.8%)
Use of protocols and
difficult airway
algorithms
Utilization of alternate
airway adjuncts

• 97% of women were successfully intubated at direct laryngoscopy.

• Failed intubation rate 1:232
GA continued and managed successfully with SGA
Positioning [head up tilt]
Positioning [head up]

Improves FRC
IIM Lowers the risk of aspiration

Easy bag mask ventilation& intubation

Reduntant tissue falls away from chest

Easy Laryngoscopy

Increase apnoea time

Hignett R, Fernando R, McGlennan A, et al. Does a 30º head-up position in term parturients increase
functional residual capacity? Implications for general anaesthesia. International Journal of Obstetric
Anesthesia 2008; 17: S5.
 Preoxygenation : whats the recent
trend
• End-tidal oxygen fraction
(FETO2) is the best marker of
lung denitrogenation
• An FETO2 ≥ 0.9 is recommended

2 min Preoxygenation is
adequate for the term
pregnant woman
UTILIZING
End Tidal oxygen fraction
monitoring

McClelland SH, Bogod DG, Hardman JG. Pre-oxygenation in pregnancy: an investigation using
physiological modelling. Anaesthesia 2008; 63: 259–63.
New techniques for preoxygenation

Nasal cannula with 5-15 L/min1

Oxygen flow before starting
pre-oxygenation

to maintain bulk flow of

oxygen during intubation
attempts
 RCT: 73 term participants underwent a 3 min HFNO protocol (30 L min1 for 30 s, and
then 50 L min1 for 150 s)
The etO2 was assessed for the first four breaths after simulated preoxygenation
The primary outcome was the proportion who achieved etO2 90% for the first
expired breath.

The proportion with first expired breath etO2 90% was 60%
[95% confidence interval (CI): 54- 66%]

HFNO using 3 min protocol is inadequate to

preoxygenate term pregnant women
Rapid sequence with cricoid ?

n = 4,891 intubated GA emergency CB,

In 61% cricoid pressure applied.
11 deaths from aspiration [ 9 parturient had CP applied]
CP is still the GOLD STANDARD Poor Laryngoscopic View

Difficulty in ETT Placemant

Hinders insertion of SGA

Increased risk of AAGA

So should have low threshold for its release

 Should be ready to reapply cricoid

pressure
 Apply head-down tilt
And
 suction the orophyarynx
Airway Adjuncts: RSI &VL

In patients with an anticipated difficult airway

undergoing category 1 CD for fetal distress
surgical anesthesia was established with GA
using RSI and video laryngoscopy
in a significantly shorter time (100 seconds)
than spinal anesthesia (6.3 minutes).
VL with obstetric airway friendly
features
King Vision (Ambu)
portable video
laryngoscope
• Can be inserted
separately
• Once positioned in the
oropharynx the monitor
can be attached
VL: Potential Disadvantage
Pharyngeal trauma has been associated with the use of video
laryngoscopes, requiring a stylet to facilitate intubation

Cooper RM. Complications associated with the use of the

GlideScope videolaryngoscope. Can J Anaesth. 2007;54(1):54-57.
VL : Potential Disadvantage
Longer apnoea time required to intubate the trachea compared with
conventional laryngoscopy.

To date, there is no evidence that this longer period of apnea

is of any clinical significance.

Sun DA, Warriner CB, Parsons DG, et al. The GlideScope video laryngoscope: randomized clinical
trial in 200 patients. Br J Anaesth. 2005;94(3):381-384.
Airway Adjuncts: SGA
Recommendation
If tracheal intubation is not
considered , and there is small
increased concern about
regurgitation risk:
2nd generation SGA is more logical

All hospitals should have availability

of 2nd SGA for routine & rescue
airway management
 More evidence supporting
the safety of LMAs
• RCT n=80

Easier insertion & less

hemodynamic disturbances
Low incidence of sore throat
 RCT: 920 PARTURIENTS

[460 SLMA & 460 ETT]

SLMA : Reduced time to effective

ventilation

Comparable maternal/ neonatal

outcomes
 What induction agent is most appropriate for
general anesthesia for cesarean delivery?

Thiopental is still the most popular induction

agent for general anaesthesia in obstetrics

Current opinion suggests that the

induction dose of thiopental for the
healthy parturient should be no less
than 5 mg/kg

Pandit JJ, Cook TM, the NAP Steering Panel. NAP5. Accidental Awareness During General Anaesthesia.
London: The Royal College of Anaesthetists and Association of Anaesthetists of Great Britain and Ireland, 2014
• RCT: 70 parturients
Group P: 2mg/kg propofol
BIS values from induction to the eighth minute
Group T: 5mg/kg thiopentone
and skin incision, uterine incision and removal
of the infant were lower in Group P.

5-minute APGAR scores, cord blood gas

values were comparable
 Thiopental versus propofol on the outcome of the newborn after
caesarean section: An impact study
Olivier Montandrau et al. Anaesthesia Critical Care & Pain Medicine
Volume 38, Issue 6, December 2019, Pages 631-635

Jan 2009-2013 newborn ↓GA

5-minute Apgar Score < 7 was not influenced

367 newborns were enrolled, by the use of propofol (OR 1.40 [CI 95% 0.90–
178 in thiopental group and 2.20] P = 0.135).
189 in propofol group.
The median (IQR [range]) time to reach SpO2
of 95% was significantly shorter in Group S
(358 (311–373 [215–430]) s)
than in
Group R (378 (370–393 [366–420]) s; p =
0.003),and shorter in Group SO (242 (225–258
[189–370]) s)
 240 parturients
• ROC group (muscle relaxation
induced with rocuronium 1 mg/kg
• SUX group (succinylcholine 1
mg/kg for induction,
rocuronium 0.3 mg/kg for
maintenance,
• The mean time to tracheal intubation
was 2.9 seconds longer in the ROC
group
• No statistically significant differences
in incidence of anesthesia complicatio
ns or in neonatal outcome were found
(10-minute Apgar score <7, P = 0.07;
umbilical artery pH, P = 0.43).
 How about the volatile
Awareness is a major risk
Paech et al. IJOA 2008 5 IN 1095
Pandit et al. BJA 1 IN 670

Obstetric cases account

for 0.8% of general
anaesthetics in the NAP5
Activity Survey
but ~10% of reports of AAGA to
NAP5
 Use of inhalational & nitrous
oxide
Adequate end-tidal volatile levels should be achieved by using a
high initial concentration of volatile agent (‘overpressure’) combined
with high fresh gas flows.

The additional use of nitrous oxide in adequate concentration as a

carrier gas during Caesarean section can reduce the amount of
volatile agent required and it does not decrease uterine contraction

Bogod D, Plaat F. Be wary of awareness—lessons from NAP5 for obstetric

anaesthetists. Int J Obstet Anesth 2015; 24: 1–4
And how much volatile during
maintenance ?
• Suggest near 0.75- 0.8 MAC
e.g.≥ 1.5 % sevoflurane
3% desflurane
0.75 vol% isoflurane
AND
50% nitrous oxide+ 50% oxygen
 Should opioid be used as part of the induction
of a general anesthetic for caesarean delivery?
Opioids have traditionally been avoided as • Neonatal respiratory depression
part of a standard RSI for Caesarean • Potentially delay the return of
section because these drugs cross the spontaneous ventilation in the mother
placenta in the event of a failed intubation and
discontinuation of anaesthesia

However, these concerns

are not evidence-based.
 Consensus regarding the use of opioids in LSCS

Opioids confer the maternal benefit • Blunting the hemodynamic response to

laryngoscopy & intubation
• ↓ Hypnotic requirement
• ↓ The incidence of AAGA

Remifentanil boluses of 1 µg/kg, when combined with a hypnotic induction,

effectively blunt the hemodynamic response to laryngoscopy, and its rapid
onset and short duration closely match the clinical goals

Approximately 10% of neonates required naloxone for

respiratory depression
EXTUBATION AND POSTOPERATIVE CARE

Airway complications occur at extubation and recovery

Obstetric patients should be extubated awake in the head-up

position once neuromuscular blockade has been reversed.
Postop analgesia after GA
-analgesics
• Multimodal :regular paracetamol & NSAID
• TAP block
Comparative literature of LSCS
↓GA vs SAB
 CONCLUSION
Intervention : SB, Prospective
study The total operation time was
longer in the spinal
anaesthesia group: 69±13.3
Participants: 100 parturients min vs GA 62.4± 13.4 min
SAB=50
GA=50
The Spinal anaesthesia
speeds up recovery time
 General anaesthesia is associated with the most rapid
operating room-to-incision interval for category-1 CS
With ↓sd APGAR at 1 min &5 min and comparable at 10
min

Have a low threshold to use GA, if it appears safe and is

appropriate to minimize ORII time in category I LSCS
Category 1CS, 114 parturients
One and 5‑min Apgar scores were
significantly lower in the (GA) than
Group GA (n=67) (SA)
Group SA (n=47)

The umbilical cord blood pH was

comparable (7.21 ± 0.15 vs 7.25 ± 0.11 in
DDI &UIDT: Comparable groups GA and SA
Legal Aspects Of Failed Spinal

Szypula et al analyzed litigation related to

regional anesthesia in the United Kingdom and
found that pain during CD or labor was the
most common “damaging event” in obstetric
patients (57/186 claims)

Szypula K, Ashpole KJ, Bogod D, et al. Litigation related to

regional anaesthesia: an analysis of claims against the NHS in
England 1995-2007. Anaesthesia. 2010;65(5):443-452
Key Message

Propofol is very widely used

Opioid pre delivery is new trend

Choice of sux /roc presents new

debate

Initial overpressure with sevo+

N20 +O2 is rational
Take home message
GA should neither be widely used nor consistently
avoided

Difficult airway management is important, appears of

diminishing concern

Awareness remains a significant concern

Thanks