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Spinal Anesthesia for Cesarean Section Immediately Following Labor Epidural Analgesia: A Retrospective Review of Failure Rate, High Spinal Rate, and Spinal Dose Used
Abstract Number: T5D-3
Abstract Type: Original Research
STUDY OBJECTIVE: Measure the failure rate, high spinal rate, and spinal dose for subjects who receive a spinal anesthetic for cesarean section immediately following labor epidural analgesia.
METHODS: Subjects with labor epidurals who subsequently underwent cesarean sections with a spinal anesthetic from February 1, 2014-July 31, 2017 at our hospital were included. Demographic and obstetric data were recorded along with number of epidural boluses before caesarian section, spinal dose (0.75% bupivacaine with dextrose), administration of phenylephrine, ephedrine, ephinephrine, nitrous oxide, ketamine, propofol, bicarbonate, and fentanyl (intravenous, intrathecal and epidural) during the procedure, and times between admission and delivery, admission and neuraxial placement, and epidural and spinal placement were retrieved from the electronic medical record.
RESULTS: 89 subjects met inclusion criteria for the study. 83 subjects completed cesarean sections under spinal anesthesia; one of these patients had a documented high spinal that did not require intubation. Six patients required conversion to general anesthesia due to inadequate analgesia. The median spinal dose was 1.2 ml bupivacaine 0.75% (with dextrose) and the range was 1.0-2.0 ml. 33, 29, 14, 6, and 7 subjects had 0, 1, 2, 3, and 4 or more clinician boluses administered during labor, respectively.
CONCLUSION: Our practice aggressively employs spinal anesthesia for cesarean sections when labor epidural analgesia has been suboptimal. Our median spinal dose of 1.2 ml bupvicaine 0.75% (with dextrose) provides possible guidance for practitioners who wish to adopt this technique. Our high spinal incidence was very low with only 1 out of 89 patients experiencing this complication. Our incidence of conversion to general anesthesia (6.7%) is higher than rates previously cited (<6%) in the literature2. The large number of our subjects who had no clinician boluses given during labor (33) who underwent spinal anesthesia was likely due to non-reassuring function of the labor epidural at the time of cesarean section; there is incomplete documentation in the medical records to make any further conclusions. Our success rate and low rate of high spinal blockade may suggest that labor epidural infusion rate, concentration, and time from cessation of epidural infusion to spinal dose, which had incomplete data points in our study, have little effect on outcomes; further prospective data is needed to answer this question.
1. S.H. Halpern, A. Soliman, J. Yee, P. Angle, A. Ioscovich; Conversion of epidural labour analgesia to anaesthesia for Caesarean section: a prospective study of the incidence and determinants of failure. Br J Anaesth 2009; 102 (2): 240-302. Doi: 10.1039/bja/aen352
2. Obstetric analgesia and anesthesia. Practice Bulletin No. 177. American College of Obstetricians and Gynecologists. Obstet Gynecol 2017; 129:e73-89