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Complications of spinal anesthesia for cesarean delivery following inadequate labor epidural
Abstract Number: F-14
Abstract Type: Original Research
High spinal block has been reported in patients who undergo spinal placement for cesearean delivery (CD) following inadequate existing labor epidural or failed top up. There is limited data, however, describing the incidence of failed spinal anesthetics in this situation. The purpose of this study was to investigate the incidence of high blocks and failed blocks in patients who received a spinal for CD after an inadequte labor epidural, and whether these outcomes were impacted by the administration of an epidural top up topped prior to spinal dosing.
After IRB approval, we searched the perioperative database from 2003-2012 for laboring women with an existing epidural who needed CD and received either spinal or combined spinal epidural because the epidural was deemed inadequate. Inadequate surgical anesthesia (failure) and high spinal following the spinal anesthetic were the primary outcomes. Failure was defined as need to repeat the neuraxial technique to obtain adequate block height; convert to general anesthesia secondary to pain or inadequate block height after spinal; or supplement with nitrous oxide or intravenous agents. High spinal was defined as need to convert to general anesthesia within the first 20 minutes after initial block due to weakness, altered mentation or respiratory distress or recorded block height ≥ T1. Patients were divided into two groups based on whether they had received a top up dose (≥ 100mg epidural lidocaine) prior to spinal administration. Kruskal-wallis test and Chi-square test were used for analysis. We also performed a multivariable analysis with failure as the outcome, and age, bupivacaine dose and receipt of an epidural top up as predictors.
The results are summarized in the table. Overall, there were 29 (11%) failed spinals and 9 (3%) high spinals. The incidence of failed spinals was significantly higher in those patients who received an epidural top up than those who did not (24% versus 4%, p<0.001). The incidence of high spinals was not different between the groups. In the multivariable model, receipt of a top up dose was a significant predictor of failure (p=0.0005), whereas the other predictors were not.
Administration of a spinal anesthetic following a topped up epidural is associated with a high risk of failure. This may be due in part to the presence of a large volume of local anesthetic in the epidural space, which may be mistaken for cerebrospinal fluid.