An audit of 115 parturients requiring spinal anesthesia for cesarean section in the setting of an inadequate, pre-existing epidural block. Median dose of 9.38 mg of bupivacaine + 15 mcg fentanyl was used. No patients received an epidural bolus within 30 min of their subarachnoid block.

There were no cases of total spinal block.

Because total spinal after inadequate epidurals had been 'not uncommon' in the department, the researchers had altered the department's practice to be:

1. Ensuring at least 30 min since last epidural bolus.
2. Reducing spinal dose by 20%. (NB: plain bupivacaine used)
3. Delay supine positioning for 2 min after spinal performed.

(Plus patient weight < 120 kg and height > 1.47 m)

summary

• P Dadarkar, J Philip, C Weidner, B Perez, E Slaymaker, L Tabaczewska, J Wiley, and S Sharma.
• Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas 75390-9068, USA.
• Int J Obstet Anesth. 2004 Oct 1;13(4):239-43.

BackgroundHigh blocks have been reported when spinal anesthesia is used for cesarean section following inadequate labor epidural analgesia. We have therefore modified the practice at our institution to minimize this risk and conducted a retrospective observational study of outcome following the change of practice.MethodThe records of 115 women with inadequate epidural labor analgesia who required cesarean section between July 1998 and January 2002 were studied. No epidural boluses were administered in the 30 min preceding spinal anesthesia and a reduced spinal dose, median (range) 9.38 mg (7.5-11.3 mg) of 0.75% hyperbaric bupivacaine and fentanyl 15 microg (10-25 microg) was used. Patients were left sitting for 2 min and then positioned supine with left uterine displacement and were closely monitored for symptoms or signs that would suggest a high block.ResultsNo parturient developed a high spinal necessitating intubation, and there was no adverse neonatal outcome.ConclusionThese findings do not conclusively establish this method as safe, but should spinal anesthesia for cesarean section following suboptimal labor epidural analgesia be considered, avoiding epidural boluses immediately preceding spinal injection, using a lower spinal dose, and delayed supine positioning following spinal injection may be advisable.

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