MANAGEMENT OF HIGH SPINAL BLOCK
MANAGEMENT OF HIGH SPINAL BLOCK
1. Recognition of high spinal and call for help
2. If only circulatory compromise:
Correction of bradycardia and hypotension.
Lateral displacement of uterus manually, with a wedge under the patient or by tilting the theatre table. Vagolytics like Atropine 0.6mg can be useful for severe bradycardia.
For hypotension, Phenylephrine13 boluses of 50-100mcg can be given. It can also be given as an infusion 20-40ml/hr (in a concentration of 100mcg/ml or as per hospital protocol).
Ephedrine in 6mg boluses can also be given if there is hypotension and bradycardia.
Metaraminol boluses of 0.5mg or as an infusion in a concentration of 0.5mg/ml.
Mephentermine14 has been used as a 3-5mg intravenous bolus or intravenous infusion of 2-5mg/min, or 25-50mg intramuscularly. Limited information is available regarding placental transfer and foetal metabolic effects, although it is a popular agent in a number of low and middle-income countries.
IV fluids -500ml to 1 litre to be given rapidly. To be cautious in cardiac patients and in those with pre-eclampsia.
Reassure the patient as she might be nauseous and will feel faint. Keeping a conversation also will help to assess if the neuraxial block is ascending.
3. If circulatory and respiratory compromise +/- neurological deterioration
If neuraxial block is ascending with breathing difficulties and desaturation, then reassure the patient, assess the airway, and give supplemental oxygen.
If the patient loses her airway, becomes sedated or unconscious, then secure the airway which includes intubation with Rapid Sequence Intubation (RSI).
If high doses of vasopressors are required, consider epinephrine boluses of 50-100mcg (epinephrine dilution of 100mcg/ml) or infusion.
Maintain anaesthesia as there is possibility for awareness in an apparently unconscious patient.
Patient will have to be sedated and ventilated until neuraxial block has worn off, so intensive care will need to be involved.
In the event of a cardiac arrest, immediate cardiopulmonary resuscitation (CPR) as per Advanced Life support and to start perimortem caesarean section within 4 minutes of arrest.
4. Foetal monitoring
Assess the foetal wellbeing. If compromised, then the obstetric team to consider emergency delivery of foetus.
5. To rule out other causes of cardiovascular deterioration.
These causes may include local anaesthetic toxicity if intravascular injection, thromboembolism, major haemorrhage, amniotic fluid embolism, profound vasovagal effect
6. Written documentation of the events is of utmost importance for continual care of patient, for future reference and for medico legal purposes.
7. After patient has been resuscitated and woken up (if applicable), update the patient and family on course of events and offer follow up if needed.
Source: https://www.wfsahq.org/resources/update-in-anaesthesia
