Failed Spinal Anesthesia:

Mechanisms, Management,
And Prevention
Jeanne Thea De Perio, MD
Case
• C.B.
• 17 y/o
• Female
• Nampicuan, Nueva Ecija
• Chief complaint: Abdominal pain
• No known co-morbid conditions
• Non-smoker; non-alcoholic beverage drinker
• ASA PS I “E”
Case
History of Present Illness
• 10 hours PTA- epigastric pain that later migrated to RLQ
(+) Nausea and Vomiting
(+) decrease in appetite
(-) fever, dysuria, flank pain
consult at a private clinic where urinalysis and CBC was
done; with the initial impression of Acute Appendicitis and was
referred to our Institution
Admit
Case
• Past Medical History
• Family History
• Personal and Social History Unremarkable
• Review of Systems
Case
Physical Examination
• BP: 110/70mmHg, CR: 89bpm, RR: 20cpm, temp: 37.1C. ; wt. 43kg
• Conscious and coherent and not in cardiorespiratory distress
• Lungs: Symmetric chest expansion, clear breath sounds
• Heart: Adynamic precordium, normal rate, regular rhythm, no murmurs;
• Abdomen: flat, with noted guarding, (+) Indirect and Rebound tenderness, (+) Dunphy’s
sign.
• Airway assessment: Mallampati 1, mouth opening is more than 3 fingerbreadths,
thyromental distance of more than 3 fingerbreadths with good dentition
• Nuerologic exam:
• Sensory: 100% on all 4 extremities
• Motor: 5/5 on all 4 extremities
Case
• Laboratory Results
CBC Protime aPTT Urinalysis Normal
Hemoglobin 128   Result Normal Patient 31.8sec
Value Chest X-ray Essentially
Hematocrit 0.39 Patient 10.8 12-14 Normal 26.1- normal CXR
WBC 14.4 sec Value 36.3sec
Control 11.4   Control 31.5sec
Neutrophil 0.88 sec Pregnancy Negative
% 133.4% 79-     Test
Lymphocytes 0.11
Activity 100%
Platelet 258 INR 0.91      
ISI 0.91      
Case
• Preoperative Diagnosis:

Acute Appendicitis; Rule-out Gynecologic pathology

• Plan:

for Emergency Appendectomy under Subarachnoid Block.

Perioperative Course
Perioperative Course

6:55 AM 7:03 AM 7:20 AM

• After 15minutes (7:35 AM), no block resulted.
• Block failure noted
patient was brought to the•
● left lateral decubitus
●

Spinal Anesthesia abandoned

Aseptic technique,
●
sterile drapes placed
repeat injection was done
●

operating room, • level L3-L4 space

●
level L2-L3 space ●
Anesthetic technique
Spinal Needle G25
● shifted to General Endotracheal
monitors were applied: NIBP, pulse
● midline approach ●

Anesthesia. midline approach

●

(+)CSF, (-) blood

(+)CSF, (-) blood
●

oximeter, ECG. ●
Hyperbaric Bupivacaine (Ultracaine) 20mg was injected
●

●
Pre induction vital signs were BP: ●
(+) birefringence on aspiration pre- and post- injection ●
Hyperbaric Bupivacaine
●
Post-induction BP: 120/70mmHg
120/70 mmHg, HR: 118bpm, RR: ●
Trendelenburg position. (Ultracaine) 20mg
●
Motor Test: able to raise both legs
17cpm, O2 sat 100%. ●
Pinprick test: still able to appreciate and differentiate sharp
●
(+) birefringence on aspiration
●
Patient was given Midazolam 2mg and dull sensations.
pre- and post- injection
●
Temperature sensation test: still able to feel cold sensation.
prior to induction ●
No Block ●
Block testing was repeated
Perioperative Course

7:40 AM 7:55 AM 8:50 AM

• Post-operative Diagnosis: ●
Anesthesia ended at 8:50 AM
Pre induction vital signs:
● ●
Procedure started
Acute Suppurative Appendicitis ●
patient was noted to have
BP: 120/70mmHg, HR: 115bpm, RR:
●

20cpm, 02 sat 99%. ●

Anesthesia maintained spontaneous breathing and intact
●
Pre-oxygenation at 8LPM Gag Reflex.
●
Fentanyl 50mcg with Sevoflurane at ●
Patient was also noted to be able to
●
Propofol 86mg move both lower extremities
●
Roccuronium 21.5mg MAC 4. ●
Patient was then transferred to
●
After 2-3 minutes after relaxant given,
direct laryngoscopy and intubation of the
●
Procedure ended at PACU
●
Patient was later transferred to ward
trachea with a cuffed tube was done. 8:45 AM. 2 hours post-op
Discussion
 Failed Spinal Anesthesia: Mechanisms,
Management, And Prevention

• ‘Two conditions are, therefore, absolutely necessary to produce spinal

anesthesia: Puncture of the dura mater and subarachnoid injection of
an anesthetic agent.’ – Gaston Labat, 1922
Failure
• Spinal anesthetic was attempted, but no block resulted
• A block results, but is inadequate for the proposed surgery.
• extent
• quality
• duration of local anesthetic action
• Less than 1%.
• Most of the failures were judged to be ‘avoidable’
• ‘Errors of judgement’ as the major factor
Failure
• Block failure is usually ascribed to one of three aspects:
• Clinical technique
• Inexperience
• Failure to appreciate the need for a meticulous approach
• Five phases of an individual spinal anesthetic
• Lumbar puncture
• Solution injection
• Spreading of drug through CSF
• Drug action on the spinal nerve roots and cord
• Subsequent patient management
Mechanisms
• Failed lumbar puncture
• Solution injection errors
• Inadequate intrathecal spread
• Ineffective drug action
• Failure of subsequent management
Failed lumbar puncture
• Inability to obtain CSF

Failure to obtain CSF flow

despite an apparently
A needle with a lumen blocked
The needle and stylet should successful needle placement(s)
at the outset
be visually checked before should raise the suspicion of
Poor positioning of the patient
starting the procedure. needle blockage and prompt
incorrect needle insertion
needle withdrawal and “flush
test” to assure patency
Failed lumbar puncture
• Positioning
• The patient is placed on a firm surface; the lumbar laminae and spines are
‘separated’ maximally by flexing the whole spine (including the neck), the
hips, and knees; rotation and lateral curvature of the spine are avoided
• A useful position tip is to ask the patient to “try to touch their knees with
their chin”.
• This typically leads to a satisfactory flexing of the spine and facilitates needle
passage into epidural or subarachnoidal space.
Failed lumbar puncture
• Needle Insertion
• Line between the anterior superior iliac spines: Tuffier’s Line
Failed lumbar puncture
• Adjuncts
• calm, relaxed patient is more likely to assume and maintain the correct
• light anxiolytic premedication contributes much to relaxing the patient
position, so explanation (before and during the procedure) and gentle,
• for patientpatient
unhurried in pain,handling
systemicare
analgesia
vital; helps considerably
• Pseudosuccessful Lumbar Puncture
• potential source of fluid mimicking CSF is the presence of a congenital
arachnoid cyst: Tarlov cysts
Solution Injection Errors
• Dose Selection
• Has only a small effect on the extent of a spinal anesthetic, but is far more
important in determining the quality and duration of block.
• The actual dose chosen will depend on:
• The specific local anesthetic used
• The baracity of that solution
• The patient’s subsequent posture
• The type of block intended
• The anticipated duration of surgery
Solution Injection Errors
Loss of Injectate
-Luer connection between To avoid this, the syringe containing the injectate must
●

syringe and needle provides be inserted very firmly into the hub of the needle, and
that a subsequent check is made that no leakage occurs
a ready opportunity for
leakage of solution.

Misplaced Injection
-Displacement of the Fluid aspiration, after attachment of the syringe,
●

needle tip from should confirm free flow of CSF and, thus, that
subarachnoid to epidural the needle tip is still in the correct space
space
 Solution Injection Errors
Misplac ed Injection
Tip d isplacement must be guarded agai nst with an y typeo f sp inal needle, particu larly wit h
th e‘p enci l po int ’ needles
Th eo peni ngat th een d o f th esen eed les i s pr oximal to th eti p, s o o nly aminor degreeo f
‘b ackward’ mo vement d uri ng syrin geatt ach men t may result in epid ural inj ecti on
Th eo peni ng, bein gmuch lo nger may ‘straddl e’ th ed ura so t hat someso luti on reach es t he
CSF, and s ome the epi dur al s pace

Rota
tion
of
the
need
le
throu
gh
360
after
the
initial
appe
aranc
e of
CSF,
and
befor
e
chec
k
aspir
ation
The
rotati
on
redu
ces
the
risk
of
the
mem
bran
e
edge
s
catch
ing
on
the
open
ing.
Inadequate Intrathecal Spread
• Anatomical Abnormality
• Complex interaction between the anatomy of the spinal canal, the physical
properties of the solution, and gravity.
• Anatomical abnormalities that lead to problems with spread; kyphosis, or
scoliosis, may interfere with the process
• Ligaments that support the spinal cord within the theca form complete septae
and act as longitudinal or transverse barriers to local anesthetic spread
• Spinal stenosis
• Larger than usual volume of CSF in the lumbar theca
• Dural ectasia
• Marfan’s syndrome and in some other connective tissue disorders
Inadequate Intrathecal Spread
• Density of the Local Anesthetic Solution
• Isobaric
• spread through CSF is by local turbulent currents and diffusion
• results in a block of somewhat unpredictable with a relatively slow onset to maximal
block height.
• tends to give reliable anesthesia to the lower extremities with limited spread to the
thoracic level. Results in less risk of cardiovascular instability.
• Hyperbaric
• travels by bulk flow under the influence of gravity “downward” along the curvature of
the spine
Drug Failure
• Injection of Incorrect Drug
•• syringe swaps
universal use of syringe labels
• Physicochemical
• meticulous preparation,
Incompatibility
reducing the number of unnecessary drug ampoules on the tray, and adopting
a consistent
• Interaction system for
between drawing
local up solutions
anaesthetic and adjuvant.
• always using a certain size of syringe for each particular drug.
• generate an obvious precipitate; pH of the local anaesthetic solution becomes even lower that
would decrease the concentration of the un-ionized fraction that diffuses into nerve tissue and a
decreased effect could result
• Inactive Local Anesthetic Solution
• ester-type local anesthetics
• amide-linked drugs
• Local Anesthetic Resistance
• Sodium channel mutation that renders the drugs ineffective
• history of repeated failure of dental or other local anesthetic techniques
Failure of Subsequent Management
• Testing the Block
• Common techniques include testing for motor effect by asking the patient to
move his or her legs and then testing the different sensory modalities, such as
light touch, cold, or pinprick sensation
Management of the Failed Spinal
Anesthesia
• After the subarachnoidal injection, the anesthesia provider should
closely monitor the patient for the expected signs of neuraxial
blockade
• Lack of autonomic response or slower-than-expected development of
motor or sensory block should alert the clinician the potential of
inadequate or failed spinal anesthesia
• If 15 minutes have lapsed since intrathecal injection and the spinal
block does not follow a typical onset pattern, anticipated, it is highly
likely that the spinal anesthetic will be inadequate for surgery and
additional anesthetic interventions will be required
Repeating the Block
• If no appreciable block is seen at 15–20 minutes, then the most
logical step is to repeat the injection, taking steps to eliminate the
proposed cause of previous failure.
• Unless the previous injection is a complete failure, repeating
subarachnoidal injection should not be done routinely.
• High concentrations of local anesthetic intrathecally can be
neurotoxic, and repeating the procedure may lead to such a
concentration, particularly if there is an anatomical barrier preventing
spread.
Repeating the Block
• A restricted block may be because of some factor, probably anatomical, impeding
the physical spread of the solution, and it may have exactly the same impact on a
second injection, resulting in a high concentration of local anesthetic at or close to
the site of injection
• 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 possibility
• Barriers to spread within the subarachnoid space may also affect epidural spread
(and vice versa), so an attempt at epidural block may not succeed either.
• A block of inadequate cephalad spread might be overcome by repeating the
injection at a higher level, but should perhaps only be attempted when the
indication for a regional technique is considerable
Recourse To General Anesthesia
• 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 be
considered if one or two simple measures have not rectified matters
Postoperative Management
• Documentation and Follow-up
• patient should be given a full explanation of events
• inadequate spread has been the first indication of pathology within the
vertebral canal. Therefore, it may be appropriate to look for symptoms and
signs of neurological disease
• Investigating “Faulty” Local Anesthetic
• Lack of effect following a technically undemanding procedure or multiple
failures within the same theater or department raises the possibility of a
faulty batch of local anesthetic
SUMMARY
• With proper technique, training, and meticulous attention to detail,
failure rate of spinal anesthesia should be less than 1%.
• Good communication and appropriate management can mitigate
against many of the common difficulties.
• Even best practice cannot completely eliminate the possibility of
failure; thus, the careful assessment of the adequacy of the spinal
blockade and management strategy should the failure occur
intraoperatively should always be contemplated.
Reference
• British Journal of Anaesthesia
• NYSORA