Case Presentation: High Spinal in Obstetrics - PowerPoint Presentation

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Case Presentation:High Spinal in Obstetrics

Presented By:

Dr. Ahmed Naeem

PG-I, Dept of Anesthesia, FMH

Case Data

A 34 year old booked female was brought into operating room on 8

th

September with 37+4 Weeks Gestational Amenorrhea for Elective - Lower Segment Cesarean Section

She had history of Previous two LSCS under Spinal Anesthesia both of them were uneventful

Patient was normo-tensive, non-diabetic and had no other co-

morbids

, with an uneventful Antenatal Period

Pre-Op Vitals: Blood Pressure = 116/87mmHg, Pulse Rate = 95/min, Sp02= 99% on Room Air, Temp=98.6F,

Wt

=63kg

Labs: Hb=10.9g/dl, TLC:10.5x10

3

/ul , Platelet Count:317,000

Patient had a NPO of 12 Hours and her Aspiration Prophylaxis was confirmed prior to shifting to OR

Systemic Physical Examination of the patient was unremarkable

Patient Gave History of being Allergic to Amoxicillin

Administration of Block

3-Lead ECG, Pulse Oximeter and BP cuff was used for monitoring of vitals intraoperatively, A 20G IV Line was in-situ and was confirmed to be in optimal working order

1000ml Lactated Ringer was started as IV Fluid prior to the administration of neuraxial block

Patient was given Spinal Block in Sitting position with midline approach, at Vertebral Space between L3-L4 under all aseptic measures

3ml of Xylocaine 2% was used as Local Anesthetic using a 5cc Syringe and a Pencil Point Spinal Needle of 25G was used for Administering Spinal dose of Hyperbaric 2ml Bupivacaine SP (0.75%) with 0.04ml (2ug) of

Dexmetomidine

after free flow of CSF was confirmed upon

dural

puncture

Administration of Block

Patient was immediately made to lie down after Administration of Spinal block and table was tilted left;15-20 Degree to relieve aortocaval compression

5L of O2 was administered via Variable Gas Flow Face Mask through ACGO

A Blood Pressure Reading of 110/70 at Heart Rate of 89bpm was obtained & recorded 1 minute after the administration of neuraxial block

Level of Neuraxial Block was checked & confirmed by the surgeon and the anesthetist

Critical Event

~3-4 Minutes after administration of the Block, Patient complained about Nausea, and within few seconds lost consciousness went into apnea and her HR started to drop along with HR<50bpm, SpO2<90%)

Epinephrine 30mcg was administered intravenously immediately along with IV Fluids at full drip rate, Surgeon was asked to stop the surgery, Patient was switched to Anesthesia Circuit from Face Mask and bag mask ventilation was started with 100% oxygen and help was called

Patients vitals improved with HR of ~100bpm and Sp02 of >90% after starting bag and mask ventilation & Administration of Epinephrine. A diagnosis of High Spinal was made

OR Staff was rushed to make preparations for endotracheal intubation (RSI) in case it became necessary

Meanwhile, 16G IV Line access was gained and IV Fluid was rushed to the patient

Critical Event

Patient was supplied High Flow Oxygen and had BP of ~95/65mmHg with HR:~120 bpm & Sp02: 97%. Patient was closely monitored for any signs of Bradycardia, Falling O2 Saturation and Hypotension

~2-3 minutes after initial episode patient again started losing consciousness with Heart Rate dropping to <50bpm and 02 Saturation of <90%. At this point a 0.6mg Dose of Atropine and again 50mcg of Epinephrine was administered immediately which lead to improvement of the vitals.

Rest of the Intra-operative period was uneventful & patient’s vitals remained within normal limits. Patient was shifted to Post Op ward with close vital monitoring for next 2 hours.

High Spinal & Total Spinal

A high neuraxial block is a sensorimotor block that has reached a spinal segmental level higher than that required or desired to achieve surgical anesthesia

In High Spinal, a level of block ensues such that cardiovascular and respiratory embarrassment develops, seriously

jeopardising

patient safety

A sensory level of T3 or above can be associated with significant cardiovascular and respiratory compromise and can hence be considered a high block

Involvement of the cranial nerves signifies intracranial spread of local anesthetic which can result in complete loss of consciousness and cardiorespiratory arrest

In obstetrics, sensory block of

upto

T10 is required to prevent pain and visceral discomfort during Cesarean Section

Aetiology

Positioning of patient

- Position of patient during and immediately after injection of local anesthetic

determines the cephalad spread.

Height:

Short stature can be a risk factor for a high spinal as height influences lumbosacral CSF volume and hence intrathecal spread of drug

Speed of injection:

faster injections produce greater spread with

plain solutions

, but that the effect is less marked with hyperbaric solutions

CSF Volume & Intra-abdominal Pressure:

In pregnancy, the area of central neuraxial compartment could be reduced due to venous engorgement from raised intraabdominal pressure

Baricity / Volume of Drug:

The baricity, volume/dose and injection technique have an effect on the cephalad spread of intrathecal

drug

Pre-existing epidural block:

Unexpected high block can happen when a spinal block is administered after the epidural space has been expanded – and the subarachnoid space compressed – by recent epidural top-ups in Combined Spinal Epidural Anesthesia

Other Factors:

Needle Direction, Curvature of Spine, Age

HOW TO RECOGNISE HIGH/TOTAL SPINAL BLOCK

Constant communication with the mother is very important as it will help to detect any early changes in the voice, effort of breathing or the conscious levels. Constant monitoring of heart rate, blood pressure, respiratory rate and level of neuraxial block.

Symptoms

Respiratory

system

Cardiovascular

system

Diagnosis

A

weak

cough,Nausea

or early signs of dyspnoeaRR ≥ 12–15 per minuteSpO2 ≥ 95%Hypotension but no bradycardiaHigh spinal anesthesia is unlikelyProgressive dyspnoeaWeak hand grip strength (C8/T1)Can’t touch nose (C5/C6) Ineffective coughRR: 12-15 per minuteSpO2 ≤ 95%Hypotension but no bradycardiaEarly signs of high spinal anaesthesiaUnable to speakHypoventilationSpO2 ≤ 90%Function poorHypotension ± bradycardiaHigh spinal anaesthesia is likelyUnable to speakApnoeaHypotension + bradycardiaHigh spinal anesthesia is established

MANAGEMENT OF HIGH SPINAL BLOCK

1. Recognition of high spinal and call for help

2. If only circulatory compromise

Correction of bradycardia and hypotension.

Lateral displacement of uterus manually, with a wedge under the patient or by tilting the theatre table

Vagolytics

like Atropine 0.6mg can be useful for severe bradycardia.

For hypotension, Phenylephrine boluses of 50-100mcg can be given. It can also be given as an infusion 0.5mcg/kg/min provided there is no bradycardia since phenylephrine can cause reflex bradycardia

Ephedrine in 6mg boluses can also be given if there is hypotension and bradycardia

IV fluids -500ml to 1

litre

to be given rapidly. To be cautious in cardiac patients and in those with pre-eclampsia

Reassure the patient as she might be nauseous and might feel faint.

MANAGEMENT OF HIGH SPINAL BLOCK

3. If circulatory and respiratory compromise +/- neurological deterioration

If neuraxial block is ascending with breathing difficulties and desaturation, then reassure the patient, assess the airway, and give supplemental oxygen

If the patient loses her airway, becomes sedated or unconscious, then secure the airway which includes intubation with Rapid Sequence Intubation (RSI)

If high doses of vasopressors are required, consider epinephrine boluses of 50-100mcg (epinephrine dilution of 100mcg/ml) or infusion.

Patient will have to be sedated and ventilated until neuraxial block has worn off, so ICU Admission is must.

In the event of a cardiac arrest, immediate cardiopulmonary resuscitation (CPR) as per Advanced Life support and to start perimortem caesarean section within 4 minutes of arrest

MANAGEMENT OF HIGH SPINAL BLOCK

4. Fetal monitoring

Assessment of the fetal wellbeing by Obstetrician. If compromised, then the obstetric team to consider emergency delivery of

foetus

5. To rule out other causes of cardiovascular deterioration

These causes may include local anesthetic toxicity if inadvertent intravascular injection, thromboembolism, major hemorrhage, amniotic fluid embolism, profound vasovagal effect

6. Written documentation of the events is of utmost importance for continual care of patient, for future reference and for medico legal purposes

SYMPTOMS & SIGNS

ROOT

SYSTEM AFFECTED

MANAGEMENT

Bradycardia

Hypotension+/-

Nausea

T 1-4

Cardiac sympathetic

fibres

blocked

Vagolytics

like Atropine 0.6mg

• Sympathomimetics such as Ephedrine 6 mg boluses

• Left lateral tilt /wedge

• Phenylephrine 50-100mcg boluses if no bradycardia

Rapid IV Fluids boluses

Tingling of hand with progressive weakness of hand grip

C 6-8 Arms and handsAccessory muscles of respiration Reassure patientPlus All Previous PointsDifficulty in breathingDifficulty in speakingDesaturation C3-5 Shoulder weaknessDiaphragmatic innervation involved Assess airwayOxygen supplementationProvide gentle positive pressure ventilation with a tight-fitting face mask (100% O2), including cricoid pressure (if this does not impair ventilation) May require intubationSlurring of speechSedationLoss of consciousness Intracranial spread •Call for help•Airway, Breathing, Circulation (ABC) approach•RSI with intubation and ventilation (No Propofol)•Circulatory support with sympathomimetics or vasopressors•Provide hypnosis by means of volatile agents as usual for Caesarean section under general anesthesia•Fetal monitoring

Prevention

Preparation prior to performing any neuraxial block:

Ensure airway and resuscitation equipment are present & functioning

V

asopressors and drugs essential for an emergency general anesthesia are within immediate reach

A designated emergency team and a cardiac arrest team must be identifiable

Ensure Wide Bore Intravenous Access

Preventive Measure during Block Administration:

During a spinal block, focus on:

Dose of local anesthetic required

Baricity of drug

Position of patient after spinal

C

lose monitoring of heart rate, blood pressure, oxygen saturations, respiratory rate and level of neuraxial block is necessary

Sensory levels can be tested with ice cubes, ice packs, ethyl chloride sprays, alcohol wipes or with pin-prick

Equipment

Equipment that should be available prior to the commencement of neuraxial anesthesia are as follows:

An appropriately sized face mask

A elastic bougie or an introducer

An oropharyngeal airway of an appropriate size

Equipment to deliver positive pressure ventilation by face mask or endotracheal tube, i.e. a working bag connected to an

anaesthesia

workstation or

Ambu

bag

Two laryngoscopes with working lights and blades of differing sizes which are interchangeable

Suction with an adequate length of tubing to reach the patient, and a

Yankauer

nozzle

A dedicated syringe to inflate the cuff of the endotracheal tube, should intubation become necessary

Endotracheal tubes: One of the most appropriate size for the patient, and one of size 6.0 mm internal diameter

Nonallergenic tape to secure the endotracheal tube

Pharmacological agents

Pharmacological agents immediately available for should be available prior to the commencement of neuraxial anesthesia are as follows:

Atropine:

1 mg, prepared in a 10 ml syringe as 0.1 mg/ml

Ephedrine:

50 mg, prepared in a 10 ml syringe as 5 mg/ml

Phenylephrine:

as 100mcg/ml in a 10ml Syringe

Epinephrine

: diluted as 10 mcg/ml

plus

a single

unopened

vial of 1mg

Adequate Fluids:

i.e. R/L, N/S,

Hemaccel

Muscle relaxant:

Suxamethonium 100 mg as a single unopened vialKetamine: 100mg diluted in 10ml Syringe as 10mg/ml

References

Morgan & Mikhail’s Clinical Anesthesiology 6

th

Edition

West

Sufflok

NHS foundation Trust Document no. MAT 0054

WFSA Anesthesia for Cesarean Delivery Best Practices, Dr, Gita Nath, Dr Muhammad Waseem Athar

Management of total spinal block in obstetrics Shiny

Sivanandan

, Anoop

Surendran

doi

: 10.1029/WFSA-D-18-00034

Thank You