Failed spinal anaesthesia: mechanisms, management, and prevention

doi:10.1093/bja/aep096

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 isgenerally regarded as one of the most reliable types of regionalblock methods, the possibility of failure has long been recognized.Dealing with a spinal anaesthetic which is in some way inadequatecan be very difficult; so, the technique must be performed ina way which minimizes the risk of regional block. Thus, practitionersmust be aware of all the possible mechanisms of failure so that,where possible, these mechanisms can be avoided. This reviewhas considered the mechanisms in a sequential way: problemswith lumbar puncture; errors in the preparation and injectionof solutions; inadequate spreading of drugs through cerebrospinalfluid; failure of drug action on nervous tissue; and difficultiesmore related to patient management than the actual block. Techniquesfor minimizing the possibility of failure are discussed, allof them requiring, in essence, close attention to detail. Optionsfor managing an inadequate block include repeating the injection,manipulation of the patient’s posture to encourage widerspread of the injected solution, supplementation with localanaesthetic infiltration by the surgeon, use of systemic sedationor analgesic drugs, and recourse to general anaesthesia. Follow-upprocedures must include full documentation of what happened,the provision of an explanation to the patient and, if indicatedby events, detailed investigation.

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

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This article has been cited by other articles:

P. A. Popham, P. D. W. Fettes, J.-R. Jansson, and J. A. W. Wildsmith
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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...: Philip A Popham; British Journal of Anaesthesia, 9 Jun 2009 [Full text]
Re: Failed Spinal Anaesthesia: Paul D W Fettes, et al.; British Journal of Anaesthesia, 16 Jun 2009 [Full text]
Re: Anatomical causes of failed spinal anaesthesia may be commoner than thought...: Paul DW Fettes, et al.; British Journal of Anaesthesia, 17 Jun 2009 [Full text]
Use of Luer connection syringes for spinal anaesthesia: Stuart Davies; British Journal of Anaesthesia, 23 Jun 2009 [Full text]
Can we blame the temperature?: jithesh appukutty; British Journal of Anaesthesia, 23 Jun 2009 [Full text]
Re: Use of Luer connection syringes for spinal anaesthesia: Paul D W Fettes, et al.; British Journal of Anaesthesia, 1 Jul 2009 [Full text]
Re: Can we blame the temperature?: Paul D W Fettes, et al.; British Journal of Anaesthesia, 9 Jul 2009 [Full text]
Ultrasound and spinal anaesthesia: Piotr Szawarski, et al.; British Journal of Anaesthesia, 16 Jul 2009 [Full text]
Intracranial hypotension resulting in dry lumbar puncture: Niraj Sinha; British Journal of Anaesthesia, 21 Jul 2009 [Full text]
Intracranial hypotension resulting in dry lumbar puncture: Niraj Sinha; British Journal of Anaesthesia, 21 Jul 2009 [Full text]
Re: Ultrasound and spinal anaesthesia: Paul D W Fettes, et al.; British Journal of Anaesthesia, 27 Jul 2009 [Full text]
FAILED SPINAL: EMERGING PRACTICE ISSUES: Amitabh Dutta; British Journal of Anaesthesia, 7 Aug 2009 [Full text]
Re: Intracranial hypotension resulting in dry lumbar puncture: Paul D W Fettes, et al.; British Journal of Anaesthesia, 7 Aug 2009 [Full text]
Re: FAILED SPINAL: EMERGING PRACTICE ISSUES: Paul D W Fettes, et al.; British Journal of Anaesthesia, 12 Aug 2009 [Full text]

				S. Davies, P. D. W. Fettes, J.-R. Jansson, and J. A. W. Wildsmith Use of Luer connection syringes for spinal anaesthesia Br. J. Anaesth., September 1, 2009; 103(3): 459 - 460. [Full Text] [PDF]

				K. Drasner Spinal anaesthesia: a century of refinement, and failure is still an option Br. J. Anaesth., June 1, 2009; 102(6): 729 - 730. [Full Text] [PDF]