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BJA Advance Access originally published online on May 6, 2009
British Journal of Anaesthesia 2009 102(6):739-748; doi:10.1093/bja/aep096
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© The Author [2009]. Published by Oxford University Press on behalf of The Board of Directors of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournal.org

Failed spinal anaesthesia: mechanisms, management, and prevention

P. D. W. Fettes1,*, J.-R. Jansson2 and J. A. W. Wildsmith1

1 University Department of Anaesthesia, Ninewells Hospital & Medical School, Dundee DD1 9SY, UK
2 AstraZeneca R&D SE-151 85, Sodertalje, Sweden

* Corresponding author. E-mail: paulfettes{at}nhs.net

Although spinal (subarachnoid or intrathecal) anaesthesia is generally regarded as one of the most reliable types of regional block methods, the possibility of failure has long been recognized. Dealing with a spinal anaesthetic which is in some way inadequate can be very difficult; so, the technique must be performed in a way which minimizes the risk of regional block. Thus, practitioners must be aware of all the possible mechanisms of failure so that, where possible, these mechanisms can be avoided. This review has considered the mechanisms in a sequential way: problems with lumbar puncture; errors in the preparation and injection of solutions; inadequate spreading of drugs through cerebrospinal fluid; failure of drug action on nervous tissue; and difficulties more related to patient management than the actual block. Techniques for minimizing the possibility of failure are discussed, all of them requiring, in essence, close attention to detail. Options for managing an inadequate block include repeating the injection, manipulation of the patient’s posture to encourage wider spread of the injected solution, supplementation with local anaesthetic infiltration by the surgeon, use of systemic sedation or analgesic drugs, and recourse to general anaesthesia. Follow-up procedures must include full documentation of what happened, the provision of an explanation to the patient and, if indicated by events, detailed investigation.

Keywords: anaesthetic techniques, regional; anaesthetic techniques, spinal; complications


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E-letters:

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Failed Spinal Anaesthesia
Jamil .S Anwari, et al.
British Journal of Anaesthesia, 4 Jun 2009 [Full text]
Anatomical causes of failed spinal anaesthesia may be commoner than thought...
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