Reflection on a Failed Spinal Anesthesia Clinical - Coursework Example

REFLECTION ON A FAILED SPINAL ANESTHESIA CLINICAL In the modern world spinal anesthesia is considered to be one of the most reliable methods. However, there is a risk of failure that should be taken into account. The main task of a practitioner is to minimize this risk. It is essential to know of the causes of the failure and how to prevent it. The given work will discuss the main violations in the process, which can lead to failure: main mistakes usually made in preparation, errors in drug spreading and puncture, first of all main violations of the process of patient management. The work will describe the ways, which can help minimize the possibility of errors. The given work is a reflection used in order to help understand the main error, which can occur and their prevention and management. Introduction Spinal (intrathecal) anesthesia is considered to be one of the most reliable methods due to its rather simple technique. It is easy to define if a needle is placed correctly and if the solution is successfully spread. Nevertheless, there is a possibility of failure. The spinal anesthesia failed if there was an attempt to make a block, but it was not placed as a result, and if the block was made, but it was insufficient for the planned surgery. The block is considered to be insufficient when its quality is bad, its duration is not enough or it is not intense. The given work will provide of overview of all three cases. The majority of experts who practice spinal anesthesia state that the risk of failure is very low. According to the data provided by American teaching hospital, the general number of failure amounts to 17% and all the cases are considered to be preventable. “Spinal anesthesia is not a 100% certain successful technique. Failure rates of 0.72%% to 16.0% have been reported. The cause of some failures may be due to technical inability to identify the subarachnoid space and that is obvious at the moment and understandable. The explanation for spinal block failure that occurs despite apparent technically correct injection of the correct drug can be mystifying” (Raw, 2010:99). Another investigation reported only 4% of failure happened predominantly due to not enough attention to details. In order to make spinal anesthesia as successful as possible it is necessary to minimize the risk of failure. In order to prevent the failure, it is necessary to fully recognize the possible complexities and define the ways of their avoidance (Rodgers et al, 2000). Generally speaking, the failure of spinal anesthesia usually happens due to three main reasons: wrong technique, the lack of experience, lack of carefulness and attentiveness. Such reasons are very general and can explain the cause due to which the process may go off track in each of five stages of the process (puncture, injection, drug spreading, drug action, patient rehabilitation). The issues, which can occur, can be found in different literature, but unfortunately not all the practitioners know about them (Hocking, 2004) . Equipment and material for spinal anesthesia main steps and possible mistakes The technique of local anesthesia can be carefully described only after some practice. In the given work we will try to put experience into theoretical form by providing the essential information, which can be used when managing spinal anesthesia. The person who was going to have a surgery under spinal anesthesia is a man of 53 years old. The whole process can be divided into four main phases: preparation phase, position phase, projection and puncture (Spinal Anesthesia Technique). The first phase is very important, it includes the communication with the patient informing about possible risks and the advantages of this type of anesthesia. A patient should know that such type of anesthesia implies the possibility of remembering some phases of surgery, feel something, but not pain. It is also important to inform patient that he/she will not be able to move legs for a certain period of time (Konrad et al, 1998). The first phase also implies choosing the right anesthetic and the needle. The choice depends on the type: isobaric, hyperbaric or hypobaric. Epinephrine can be added in order to make the anesthesia last longer or to make it more effective. The needles used for spinal anesthesia can be different, thus it is essential to choose an appropriate one. In older patients 22 gauge needle is usually applied, while in younger ones 25 gauge needle is used. The smaller needle can be used in young patients in order to prevent headache. It is desirable to use a spinal kit, which is prepared beforehand and contain all the necessary sterile tools for spinal anesthesia. Before the procedure starts, patient should be carefully examined, the blood group should be determined (Rodgers et al, 2000). The important stage is taking patient’s consent, because he/she should sign a document after he/she is informed about what spinal anesthesia is and possible risks. The next important stage is the positioning. This stage can be complicated, if the staff does not understand why positioning is very essential. The wrong positioning is the main cause of spinal anesthesia failure that will be discussed below. Patient may not also understand what positions to take or the communication with him is complicated by sedation. Practice shows that many assistants are very often unaware about the positions used for this type of anesthesia. Three positions are usually used: sitting, prone and decubitus. Lateral Decubitus prescribes lying sidelong and this position allows the procedure to be less dependent on the assistant’s help. Sitting is the position applied for sacral and lumbar levels. This position can’t be used for all the patients as it demands putting feet on a chair, sitting straight. The arms of a patient are hugging a pillow to round off back and open vertebral interspaces. The patient should remain in this position for several minutes, thus it is difficult for many patients, for example, if a patient is obese. Prone position is used, when a patient is going to have a surgery (Neil, 2011: 284). The choice of pharmacology depends on the time interval of the procedure. Several local anesthetics are used for spinal anesthesia. These include procaine, lidocaine, tetracaine, levobupivacaine, and bupivacaine. Local anesthetics are categorized by duration of action. Short acting spinal anesthetics are used for procedures that are < 90 minutes: procaine, lidocaine. Long acting local anesthetics are used for procedures > 90 minutes: tetracaine, bupivacaine, levobupivacaine. Local anesthetics administered for spinal anesthesia are preservative free. Preservative containing local anesthetics can be neurologically toxic and should be avoided. Dosages of local anesthetic are generalized suggestions and may need to be adjusted according to individual patient characteristics” (Local Anesthetics Used for Spinal Anesthesia). During projection and puncture phase two methods are used: paramedian and midline. Midline approach is very suitable for the doctor. It is applied only in sitting position that allows the doctor to access to L2-L3, L3-L4, L4-L5, and L5-S1. Palpation is applied to find the interspinous ligament. Then the assistant helps to prepare the sterile tray and the back should be prepared with antiseptic. Needle should be held like a pencil and it is very important to be ready to sudden movements of a patient. In case if CSF does not appear during 30 seconds, bone is encountered or a patient feels sharp pain in legs, the needle should be removed immediately and another attempt should be made, because the midline principle is violated. If all the attempts are unsuccessful, it is necessary to move to general anesthesia. Too many attempts should not be used, because it increases the possibility of trauma. “In the current literature (Raw, 2010, Hocking 2004) 19 only two attempts are recommended since multiple punctures can inflict nerve injury and predispose to haematoma formation. In our peripheral set up where there is lack of adequate facility of giving general anesthesia as well as trained man power and also where it takes hours to reach higher centre this study will helpful for our society for better outcomes for mothers and newborns” (Pokharel, 2011: 14). Therefore, this technique anesthesia, especially for patients with cardiovascular illnesses (CHD, hypertension, atherosclerotic and myocardial infarction) with respect to the fact that a lack of nociceptive changes promotes more "economical" cardiac activity, not going beyond compensatory eligible patients (Neil, 2011: 285).The main advantage of paramedian approach is the possibility to avoid anatomic limitation. The most widespread mistake is placing the needle too far from the midline. Palpation is used to find caudad tip. The needle used for this approach is longer than for the previous (Neil, 2011: 286). The next important stage after the anesthesia is successfully placed is monitoring the block. It is necessary to measure the blood pressure every three minutes. The block should be sufficient for the surgery, but not too strong. The patient may feel difficulty with breathing if the block is too strong or he/she is not able to move the arms. The level of consciousness should be also carefully monitored (Raw, 2010). In the most cases the failure happens due to medication errors. No matter what area of activity error occurs in, it is a serious misconduct that may have unpredictable consequences. Healthcare is the area of activity that requires special liability as errors of doctors can cost people much. Thus, this area needs careful administration in order to avoid unhappy accidents caused by the medication error (Hocking, 2004). When a student studies in medical higher institution, he/she is told that a healthcare professional should not make any mistakes at all, as they are not excusable in the area of medicine. Everybody makes mistakes but a doctor must not as he/she simply does not have a right to do that. “Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer” is defined by the newest legislation as a medication error (cited in Preventing Medication Errors). Moreover, medication errors usually lead to court cases. Unfortunately, the number of medication errors in the modern society is very high and tend to increase. The main reasons are the following: Ignorance of drug management rights; The absence of regular drug check. Healthcare workers are obliged to check medications before giving them to patients; The absence of appropriate patient administration. The state of patient’s health may vary so only recent tests should be taken into account when prescribing medicines; Giving drugs to patient being unsure about the dosage and medication appropriateness. There are several measures that should be necessarily taken by the nurse to prevent medical errors. The first is the appropriate evaluation. A nurse should find out if a patient has any contra-indications to this or that medicine, make necessary tests to define the state of his/her health. Secondly, it is necessary to create a plan of medicines taking, define the right dose and warn the patient about possible side effects (Hocking, 2004). The final important prevention measure is the assessment of outcomes. It is very essential to check the state of the patient in order to trace the changes in the way one feels (Preventing Medication Errors). Moving to general anesthesia in case of spinal anesthesia failure In our case the patient of 53 years old was going to have leg surgery. He was generally healthy and previously had several successful general and local anesthesias. A hypobaric solution was going to be used. “A hypobaric solution for spinal anesthesia is less dense than CSF (less than 1.0069). To create hypobaric solutions with tetracaine mix 1% tetracaine, with sterile water (preservative free). This would make the baricity of the solution less than 0.9977. For anorectal procedures and hip repairs, a dose of 4-6 mg is generally adequate. Bupivacaine becomes hypobaric when warmed to 37 degrees C. Hypobaric solutions are not used often, but have their place in clinical anesthesia. Hypobaric solutions are useful for the patient with a fractured hip or extremity. Since it is painful for the patient to lie on the affected side, positioning them with the fracture up and administering a hypobaric solution will allow the patient to be more comfortable” (Local Anesthetics Used for Spinal Anesthesia). Two milliliters of 2% chloroprocaine was going to be injected in sitting position, but after several attempts spinal anesthesia failed due to the mistake, which led to violation of midline. After three attempts the physicians decided to move to general anesthesia, mask inflational anesthesia in particular. Sevoflurane vapor and a laryngeal mask airway were applied. The technique was the following: the calf was deflated, so that it had a spoon shape, the posterior aspect of the deflated mask was lubricated. The patient was placed in sniffing position, the cuff was inserted into the hypopharynx and inflated. The ventilation device was attached. The position was checked with a qualitative end-tidal CO2 detector. (Mason). General anesthesia can be also processed with the help of endotracheal tube “A breathing tube is a plastic tube used during artificial respiration, a procedure to assist a patient in breathing. One end of the breathing (endotracheal) tube is placed into the windpipe (trachea) through the mouth or nose. The other end of the tube is connected to a breathing machine (mechanical ventilator) or breathing bag (manual resuscitator). The breathing tube provides an airway so that air and oxygen from the breathing machine or breathing bag can be provided to the lungs”( Endotracheal Tube) . The surgery was held without any incidents. Then the patient was moved to the recovery room. The monitoring of patient, who underwent a surgery under general anesthesia is the same then for those who was given spinal anesthesia. However, after spinal anesthesia block regression should be also monitored. “The patient with a spinal is more likely to experience hypotension in the postoperative period. Treatment includes a Trendelenburg position, additional intravenous fluids, oxygen, and vasopressors as needed. Urinary retention should be assessed in patients that do not have a urinary catheter. The patient should not be discharged from the recovery area until vital signs are stable and the spinal block is regressing. The patient should remain in bed until full sensory and motor function has returned. The first time a patient is ambulated, a nurse should assist the patient to ensure full function has returned” (Benumof, 1996: 686). Surgery is like a trauma for the body and straight after the surgery the patient is fully dependent. Nurses keep using artificial airway till the time when the patient is able to swallow and gag. The head of the patient should be put down a bit to prevent tongue from moving to the throat. After spinal anesthesia patient lie unmovable for 12 hours. When a nurse notices the returning of reflexes, the anesthetic effect is over. Then a nurse should inform the patient about what happened and do the best to relieve the pain. Pain is a serious alarm of the organism informing about damaging of tissues (Benumof, 1996: 687). To take control over pain and to deal with it, different researchers and scientists provided patients with a great care, but, of course, medical treatment was necessary too. There is a lacking of universal and appropriate means of pain treatment and management. Therefore, a huge number of patients are suffering from pain and are looking forward to some appropriate medical decisions, which will facilitate their suffering for sure. Of course, physicians can provide aggressive pain management, but it is better to find both effective and less damaging solutions to treat the organisms of the patients appropriately (Bergendahl, Lonnqvisy, Eksborg, Ruthstrom, Nordenberg, Bianchi, Ginggen, Tardy 2008, p. 973). The pain can be great during the first three days, during the first day analgesics are used every 4 hours. During the first days it is essential to reveal possible complications and prevent their appearance. The most widespread complications are respiratory distress and hypovolemic shock. Conclusion The advantages of spinal anesthesia should not be underestimated, thus the attempt of using it should be made. It is not necessary to turn to general anesthesia immediately after the first unsuccessful attempt, several attempts can be used, but not too many to avoid trauma. Notwithstanding that spinal anesthesia is considered to be a reliable method and it is easy to be applied, even the most experiences practitioner can fail it. “Any failed nerve block deserves to be considered a “complication” of an intervention. A complication has consequences that can force alternate interventions or therapies to be utilized which may be less favorable for the patient. In addition any outcome (such as failed spinal block) treated as a complication will receive more attention for analysis, discussion, prevention and education, all of which should benefit patients ultimately” (Raw, 2010: 101). However, in the most of cases the mistake is made due to medication error, which could be avoided. In our cases the mistake was made when midline was violated. General anesthesia was applied, mask inflational anesthesia in particular. The surgery proceeded without incidents and the patient was moved to recovery room. In the most cases general anesthesia can be avoided and local anesthesia can be successfully applied. References Mason, A Pharmacology of Inhalational Anaesthetic Drugs FRCA. Department of Anaesthesia, Hope Hospital, Salford. Local Anesthetics Used for Spinal Anesthesia accessed August 27, 2014 at http://www.medbox.org/preview/5385e0a2-8858-4d5e-82af-636f1fcc7b89/doc.pdf Benumof JL 1996, Laryngeal mask airway and the ASA difficult airway algorithm. 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