Total Spinal

This is an anaesthetic crisis
Priority is to: * Manage A-B-Cs * Deliver foetus (if relevant)

A total spinal is:

• Spinal anaesthesia involving the** brain stem**
• Difficult to predict
  May be difficult to induce even if intentional.

#####Emergency Management

Follows an ABC approach:

• A
  • Provide 100% oxygen
  • Assist ventilation if required
  • Intubate if apnoeic Patient may still be aware and not-relaxed; perform a drug-assisted intubation.
• B
  • Support ventilation as above
• C
  • Volume
    Fill dilated, compliant venous resevoir.
  • Vasopressors
    
  • Inotropes
    If bradycardia predominants. 50-100µg adrenaline is a reasonable starting point.
• D
  • Post-intubation sedation
    If required.
• Supportive therapy continues until total spinal has resolved
  May last 15 minutes to ~4 hours.

Foetal delivery:

• Foetal distress often present with maternal hypotension
• Delivery will improve maternal circulatory compromise

Epidemiology and Risk Factors

Total Spinal:

• Occurs in ~1:1000-1:5000
  Risk factors:
  • Total dose of local anaesthetic
    Higher risk with inadvertent dural puncture.
  • Baricity
    Hyperbaric solutions ↑ cephalad spread in head-down position.
  • Patient factors
    • Height
    • Anatomical
      Separations within thecal sac.
    • Weight
      Epidural venous congestion compresses intrathecal space.
  • CSE
    Epidural injection may displace spinal solution cephalad.
• Features of spinal anaesthesia
  • Rapid onset
    Usually (but not always) within 1-5 minutes.
  • High spinal symptoms
    • Bradycardia
    • Hypotension
    • Respiratory impairment
      • Difficulty once intercostals are paralysed
        Note whispering and inability to cough.
      • Severe when phrenic nerve is paralyse
        
    • Upper limb weakness
  • Cervical spine involvement

---

References