Failed neuraxial

anaesthsia- what

now?

Dr. Moira Baeriswyl

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Unsatisfactory labour epidural ?

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Inadequat analgesia (2-20%) Impossible to place KT (13%)

Insufficient analgesia Failure de find epidural space

Asymmetric analgesia (80% = right side )

Failure to thread catheter

Analgesia limited to a small number of segments

Lack of sacral block

Epidural failure ?

Hermanides BJA 2012

Insufficient analgesia

KT displacement or problem ?

Rapid progression of labour/ End of

labour / Posterior presentation ?

Insuffisant volume of LA ?

Panni MK. BJA 2006; 106-10

Insuffisant volume of LA ?

Low correlation between patient size and quantity of LA

necessary

Lower dose of LA in obese patients

Recommandations

4-8 ml

Insuffisant volume of LA ?

Migration du KT durant le W (54%)

Crosby ET. CJA 1990; 37: 789-93

0

5

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15

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>-2 -2 -1,5 -1 -0,5 0 0,5 1 1,5 2 >2

Migration du KT (cm)

Po

urc

en

tag

e d

e p

ati

en

tes

KT displacement ?

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« Lockit »

Clark MK. Anesthesia 2001; 56: 865-870

How to prevent it ?

Clark MK. Anesthesia 2001; 56: 865-870

Migration du KT Lockit

(n = 48)

Standard

(n = 54)

P

External migration 2 cm 3 (6%) 14 (26%) < 0,01

Internal migration 1 cm 0 (0%) 9 (17%) < 0,01

No significant migration 42 (88%) 15 (28%) < 0,001

« Lockit »

How to prevent it ?

RR P

Insuffisance analgesia after 1st bolus

3,5 0,001

Posterior presentation 5,6 0,001

Radiculaire pain during epidural 3,9 0,05

Length of epidural analgesia > 6h 9,1 0,001

Length of analgesia < 1h 18,3 0,001

Le Coq G. CJA 1998; 45: 719-23.

Risks factors for insuffisant analgesia

Rapid progression of labour/ End of labour/

Posterior presentation ?

Adapt analgesia (L2-S5 during expulsion)

Recommandations

- Increase volume

- Increase concentration of LA

- Use adjuvants:

• Sufentanil

• Clonidine (50-75 µg)

Rapid progression of labour/ End of labour/

Posterior presentation ?

Length of KT

(> 4cm for multi-perforated KT) ?

KT in intervertebral foramen?

KT in anterior epidural space ?

Asymetrical analgesia (80% on right side)

Deformation or spinal surgery?

Septum ou adhesions in epidural space

KT in intervertebral foramen?

Unilateral analgesia limited to 1-2 dermatome

Collier CB. IJOA 1996; 5: 19-31.

Septum in epidural space (2%)

Epidural limited to a few

segments

Collier CB. IJOA 1996; 5: 19-31.

Deformation of spine or spinal surgery ?

Collier CB. IJOA 1996; 5: 19-31.

Recommandations

- 4-8 ml of LA solution

- pull KT out 1-2 cm

- If insufficient, reposition KT:

• Another level

• Consider a spinal

• Combined Spinal

Asymetrical analgesia

Failed Spinal before CS ?

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• Failed lumbar puncture

• Positioning

• Pseudo-successful puncture

• CSF volume

• Anatomical : septa

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• Repeating:

– Insufficient block: lower

dose, higher level

– Unilateral

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Grau T. Acta Anaest Scand 2001; 45: 766-71

Control Group (n = 36)

US group (n = 36)

P

Number of puncture attempts 2,6+/- 1,4 1,5 +/- 0,9 P<0,001

Number spinal levels 1,5 +/- 0,7 1,27 +/- 0,51 P<0,05

Number of attempts to insert KT 1,3 +/- 0,6 1,1 +/- 0,6 P<0,003

Patients with asymetric epidural 5 2 n.s

Patients with inequal epidural 3 1 n.s

Failure to place epidural 2 0 n.s

VAS before epidural placement 4,2 +/- 4,1 4,1 +/- 4,1 n.s

VAS max 1,8 +/- 2,7 0,8 +/- 1,4 P<0,035

Patient satisfaction 2,1 +/- 1,3 1,3 +/- 0,5 P<0,006

Headache 4 2 n.s

Back pain 7 7 n.s

Ultrasound in difficult situations

Difficulty in finding the right space ?

Patients with BMI 33-86 kg/m²

Balki M. Anesth Analg 2009

Difficulty in finding the right space ?

Facteur Odds ratio 95% CI P

BMI (Kg.m-2)

≥ 30 versus < 30 1,9 1,0 – 3,6 0,03

Abdominal perimeter(cm)

≥ 105 versus < 105 1,5 0,8 – 2,6 0,14

Anatomical level

Grade 3 - 4 versus Grade 1 - 2 1,7 1,0 – 2,9 0,04

Deformation of spine

deformed versus normal 4,3 2,2 – 8,2 < 0,0001

First year internes finding epidural space

Faitot V et al. IJOA 2011; 20: 124-7

Difficulty finding the right space ?

Failed Top-up before incision

CS ?

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Spinal General

Intraoperative pain

with epidural/spinal

• N2O

• Alfentanil

• Ketamine

• Dexmedetomidine

• Remi

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What to do then?

• Volume

• Reposition when in doubt

• Deficient spinal: redo

• Ultra-sound

• General anesthesia: safe conditions

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