High regional or total spinal block

The incidence is 1 in 27,000 obstetric epidurals. Strictly, total spinal is the subarachnoid injection of a large (epidural) dose of local anaesthetic, resulting in severe hypotension, profound bradycardia, respiratory arrest and loss of consciousness. However, a similar result can follow epidural or subdural injection of local anaesthetic: high regional block is defined as an excessively high block requiring tracheal intubation.

Although the features (weakness of upper limbs, difficult breathing, slurred speech, sedation and high level of numbness) are typically rapidly ascending, these may develop late and insidiously.

Management

Call immediately for an ODP and a second anaesthetist.

Equipment immediately required

Cardiac arrest trolley (kept in resuscitation equipment bay by baby resuscitation room) with laryngoscope, endotracheal tubes and suction pump.

Management technique

• Position patient on her left side (or other method of uterine displacement). The patient must be positioned to eliminate aortocaval compression at all times.
• Oxygen should be administered with a mask and bag as necessary.
• 500 - 1000 mL of Plasmalyte 148/Ringer’s lactate rapidly intravenously.
• Ephedrine 15 mg intravenously. Repeat as necessary. Consider phenylephrine, adrenaline and atropine administration. Maintain the blood pressure with ephedrine or a phenylephrine infusion plusglycopyrrolate or atropine and an intravenous infusion as required.
• If breathing is inadequate, perform rapid sequence induction with cricoid pressure. The patient should be intubated and kept ventilated and anaesthetised.
• If intubation is difficult or fails, do not wait for the return of spontaneous ventilation – it may not occur. Proceed with emergency airway management and IPPV (see failed intubation drill).
• Move the patient to the operating theatre for full monitoring including blood pressure, SpO2, EtCO2 and ECG.
• In the event of fetal distress, caesarean section is advised.
• The patient and her relative(s) should be reassured; allocate a team member to escort the
  partner/relative out of the room as soon as possible. 

Consider alternative diagnoses, e.g. subarachnoid haemorrhage.

Post-event

A post delivery visit is vital to explain what has happened and why. Further follow up may be needed to deal with psychological issues.