Results: Of the 197 participants included in the analysis, the frequency of failure of spinal anesthesia in emergency cases and 9.35% in elective caesarean section). Training in general anesthesia and protocols for managing other complications of spinal anesthesia should be implemented in the hospital.
Introduction
Problem statement
Research questions
Objectives
Significance of the study
Background
6 temperature, which is two segmental dermatomes higher than pain and light touch, which in turn is usually two segmental dermatomes higher than the loss of motor function (Morgan et al., 2013).
Landmarks for spinal anaesthesia
Assessing the level of spinal block in caesarean section
Relevant anatomy
- The vertebral canal
- Contents of subarachnoid space
- Structures from skin to subarachnoid space
- The effect of pregnancy on the anatomy of the spine
The effectiveness of the spinal anesthetic is influenced by the relative density and volume of the CSF (Hocking and Wildsmith, 2004, Yağan et al., 2014). Ultrasonography improves the localization of the subarachnoid space, thereby improving the success rate of spinal blocks in obese patients (Watson et al., 2003, Abdelhamid and Mansour, 2013).
Equipment requirement
Spinal needles
This anatomical change may contribute to the misidentification of landmarks during a lumbar puncture procedure, increasing the risk of neurological injury (Lee et al., 2011). The compression of the inferior vena cava by the uterus in the third trimester also causes engorgement of the epidural blood vessels, leading to a reduction in the volume of the lumbosacral subarachnoid space (Birnbach and Browne, 2005). Hirabayashi et al., (1996) recommend that a smaller amount of anesthetic be used for spinal anesthesia in pregnant women as the epidural and subarachnoid spaces are smaller.
Failed spinal anaesthesia
The frequency of failed spinal anaesthesia
Associated risk factors of failed spinal anaesthesia
- Provider level of competency
- Quality of anatomical landmark
- Patient positioning during lumbar puncture
- Injection of anaesthetic agent
- Local anaesthetic agent
- Anxiety
Furthermore, complications such as failed spinal anesthesia were reported by obese women undergoing cesarean section with spinal anesthesia (Vricella et al., 2010; Rodrigues and Brandão, 2011; Wenk et al., 2012). Pre-spinal ultrasound has been shown to reduce the problems encountered when performing spinal anesthesia in obese patients (Chin et al., 2010). According to Inglis et al., (1995) the lateral position requires more time for spinal needle placement because it is difficult to identify landmarks compared to the sitting position.
A similar study by Laithangbam et al., (2013) described the left lateral position as being associated with a faster, higher blockage and increased tendency to hypotension. Loss of bupivacaine, the anesthetic agent, can occur due to: i) the spinal needle is partially inside or partially outside the subdural space (Fettes et al., 2009). ii) leakage of anesthetic between the syringe and the spinal needle (Fettes et al., 2009). A study by Yamaki et al., (2009) reported a case of failed spinal anesthesia caused by a spinal arachnoid cyst.
The efficacy of the anesthetic drug bupivacaine used for spinal anesthesia can be affected by an inadequate dose (Shrestha et al., 2009) and prolonged exposure to light (WHO, 2016). Studies have shown a higher incidence of failed spinal anesthesia among patients with a history of addiction to Marijuana, Tramadol and Clonazepam (Mansourian et al., 2012, Youssef and Abdelnaim, 2014). Panditrao et al., (2013) also found a correlation between an old scorpion sting and the development of resistance to the local anesthetic used for spinal block.
The complications associated with spinal anaesthesia
Hypotension
Post dural puncture headache
Setting of the study
Study population
Study design and period
Ethical considerations
23 The completed forms collected during the data collection period are currently stored in a secure location for at least three years; thereafter these records will be destroyed. Soft copies of the data will be kept confidential in a password protected computer and steps to prevent unauthorized access have been taken.
Data collection
The process and procedure
24 Women who experienced pain after twenty minutes of spinal anesthesia administration were classified as failed spinal anesthesia. Hypotension was managed by increasing the level of intravenous Ringer's lactate and administering face mask oxygen.
Research assistant
Variables of interest
Statistical analysis of data
Univariate analysis
The Chi-square test was applied to the failed spinal anesthesia and successful spinal anesthesia groups to identify a relationship between the two variables. The diagnostic performance of the BMI cut-off point was able to distinguish the incidence of failed spinal anesthesia and successful spinal anesthesia using the receiver operating curves (ROC) method for calculating the area under the curve (AUC) with its confidence interval 95% (95% CI). Associations between dependent variables and outcomes of interest were measured using relative risk (RR) and a 95% CI with a chi-square test.
Operational definitions
Demographic characteristics
Key: FSA=failed spinal anesthesia; SSpA= Successful Spinal Anesthesia; CS=caesarean section; SpA= Spinal Anesthesia;. Unsuccessful spinal anesthesia occurred in eight (40%) of the twenty women with bloody CSF, while the rest had successful blocks. There was no significant difference in age between the failed spinal anesthesia and the successful spinal anesthesia group.
Indications for caesarean section in nineteen (82.6%) failed spinal anesthesia were emergency and four (17.4%) were elective. Analysis showed that providers with less than six months of work experience were associated with a higher incidence of failed spinal anesthesia (Figure 4.6). The frequency of failed spinal anesthesia within each category of time spent in post internship training ranges from 10.1 to 11.5% (Table 4. 6).
A size 25 G Quincke needle was used in sixty-three parturients, and six (9.5%) had failed spinal anesthesia. The table below compares the distribution of failed spinal anesthesia and variation in spinal needle size (Table 4.7). The incidence of other complications of spinal anesthesia among those who had successful block is shown in Table 4.8.
Introduction
Failure rate of failed spinal anaesthesia
Furthermore, the rate of failed spinal anesthesia in this study is similar to the 11.6% reported by the American study by Weed et al., (2011). Weed et al., (2011) noted the status of the registered nurse anesthetist as a predictor of a failed block. Similarly, a study in Nigeria conducted by Rukewe et al., (2015) reported an error rate of 9.1% which was associated with the experience level of the anesthesia provider and the use of L4 or L5 vertebral levels.
The present study reported a rate lower than the 17% recorded by Levy et al., (1985), where the high rate of failure was attributed to technical errors.
Predictors of failed spinal anaesthesia
Patient related factors
Examination of the results revealed that obesity was identified as a significant and significant independent predictor of failed spinal anesthesia. An obscured landmark in obese births makes landmark identification for spinal anesthesia difficult to find (Bamgbade et al., 2009). Similarly, Wenk et al, (2012) found an almost 50% failure rate of spinal anesthesia among patients with BMI > 32 kg/m2.
On the contrary, Schulzeck et al. (2003) and Horikawa et al. (2001) reported no problems in the administration of spinal anesthesia in obese parturients. Analysis of the results showed that fifty parturients in the study were obese with a BMI ≥ 30 kg/m2 and that spinal anesthesia failed in 24% of these cases. This finding is similar to the results of Cotter et al., (2004), who found a significant association between BMI ≥ 25 kg/m2 and a higher failure rate.
The use of ultrasound to identify the site of spinal anesthesia has been shown to be useful in patients with difficult landmarks (Chin et al., 2010, Abdelhamid and Mansour, 2013). However, pre-procedural ultrasound is not practiced at Mthatha General Hospital due to lack of skills.
Provider’s experience
43 among providers who were employed for less than six months at the hospital compared to a failure rate of 10.7% for those who worked more than six months at the hospital. Applying a logistic regression model revealed that experience was an insignificant predictor of FSA (p-value). This finding was in contrast to reports from similar studies where competency levels of attending anesthetists emerged as independent predictors of failed spinal anesthesia (de Oliveira Filho et al., 2002, Adenekan, 2011).
Procedure related
Cerebrospinal fluid characteristics were documented in all patients, with twenty cases presenting with bloody cerebrospinal fluid and a significantly high incidence of failed block. The current study found no statistically significant difference in failure rates between different lumbar puncture locations. Notably, all spinal inductions at the L2/L3 intervertebral spaces were successful, while failure rates of 14.2% and 10.5% were observed at L3/L4 and L4/L5, respectively.
A block height of T5 has been found in previous studies to be sufficient for caesarean section (Sng et al., 2009, Russell, 1995). Multiple skin punctures were observed in approximately 60% of women and a higher failure rate of 29.0% was seen among those who received three skin punctures compared to 7.6% in Difficulty in locating the landmarks usually led to multiple skin punctures that could lead to complications (Ružman et al., 2014).
Rhee et al., (2010) reported that patients who received more than three puncture attempts were identified to have a higher level of dissatisfaction with spinal anaesthesia.
Complications of spinal anaesthesia
Introduction
Clinical implications and perspectives of public health
47 These findings will influence the practice of spinal anesthesia for caesarean section at Mthatha General Hospital. As with complex techniques in anesthesiology, these findings recommend that emphasis should be placed on the operator's technique-specific experience in an effort to reduce complications. Additionally, consideration should be given to introducing pre-procedural ultrasonography of the spine to find the appropriate site for lumbar puncture in obese births.
Limitations of the study
Ultrasound-guided spinal anesthesia in obstetrics: is there an advantage over the landmark technique in patients with easily palpable spines. Distance from the skin to the epidural and subarachnoid space in women in labor scheduled for caesarean section. But it's just spinal": combating rising maternal mortality rates associated with spinal anesthesia: a forum-clinical practice.
Comparison of lateral, Oxford and sitting positions for combined spinal and epidural anesthesia for elective caesarean section. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results of a review of randomized trials. An observational prospective cohort study of the incidence and characteristics of failed spinal anesthesia for caesarean section.
Can ultrasound be used by an anesthetist to identify a specified lumbar interspace prior to spinal anesthesia. Audit of intraoperative pain during caesarean section under spinal anesthesia at Edendale Hospital in KwaZulu Natal, South Africa. You were selected as a possible participant in this study because you met the inclusion criteria for the study: providing anesthesia for births scheduled for caesarean section.
To determine the frequency of failed spinal anesthesia and to identify the risk factors associated with failed spinal anesthesia. No unauthorized access to any of the information obtained in the course of the study will be permitted.
