Strategies

• Review patient labs, with particular attention to WBC count and platelet count, which may indicate infection or coagulopathy.
• Spinals can be performed in the sitting or lateral side-lying positions.
  • Sitting is more common as it is easier to place midline.
• Patient must be educated on the procedure and required positioning.
• Patient must be able to maintain the necessary position without moving during placement.

Clinical Optimization

• If the patient is on blood thinners, refer to the neuraxial anticoagulant protocol to ensure appropriate timing since the last dose.

• In anticipation of neuraxial-induced vasodilation, the patient should be fluid optimized prior to placement.
  • Evidence suggests that co-loading fluid during the procedure, rather than preloading, is beneficial.
  • Administer 1 L of crystalloid; consider 250–500 ml colloid.

• Giving ondansetron prior to the subarachnoid block may help prevent hypotension caused by the Bezold-Jerisch reflex.

• Anxiolysis may assist the patient in assuming and maintaining the required position.
  • This may be achieved with 1–2 mg IV midazolam, precedex, or an IV narcotic.

• Sodium Bicitra should be given prophylactically in anticipation of nausea associated with a drop in SVR.
  • Bicitra neutralizes stomach pH and reduces the risk of aspiration pneumonitis.

• Note baseline vitals and ensure they remain within 20% throughout the case.

• In very obese patients, a longer spinal needle may be required to access the space.

Pearls

Preparation

• Have a trash can nearby to discard supplies such as betadine sponges.
• Before donning sterile gloves, elevate the table so that the insertion site is at chest level.
• It is helpful to have an assistant for drawing up adjunctive medications such as fentanyl or duramorph.

Technical Considerations

• If having trouble accessing the spinal space, ensure proper positioning.
  • The patient may need to round out their back further to allow maximal spreading of the spinous processes.
• Ask the patient if they feel insertion pressure on one side; a slight offset from midline may direct the needle out of range.
• Generally, start at the lower end of the intervertebral space and advance slightly cephalad.
• If osseous tissue obstructs needle advancement, pull back and redirect until the needle advances smoothly.

Managing Complications

• Hypotension: due to reduction in SVR
  • Have Neosynephrine and Ephedrine readily available.
  • Ensure IV fluids are infusing wide open.
  • Consider colloid infusion.

• Bradycardia: may occur due to sympathetic blockade (T1–4)
  • Ephedrine 5–10 mg
  • Glycopyrrolate 0.2 mg
  • Atropine 0.4 mg

• Nausea/Vomiting
  • Sodium Bicitra should be given prior to block placement.
  • Zofran (dose per provider discretion) given before or shortly after placement.
  • Additional antiemetics (decadron, reglan, or phenergan) as needed.

• High Spinal *EMERGENCY*: Patient may lose the ability to breathe*This may occur if the local anesthetic dose is too high or administered too quickly.
  • Support ventilation with bag/mask if not contraindicated.
  • If the patient is pregnant or has a full stomach, induce general anesthesia and intubate.
  • Administer midazolam promptly for anxiolysis.
  • The patient may need to remain sedated and ventilated until respiratory effort resumes.

• Spinal/Post-Dural Puncture (PDPH) Headache:*May occur due to excessive CSF loss from multiple attempts or a larger gauge needle. Symptoms may begin immediately or within 24–48 hours. Headache worsens when upright and improves when supine.

• Spinal Hematoma: Rare complication (<1:150,000)
  • Typically a complication of coagulopathy during placement; may result in permanent nerve injury.
  • Prevention is key—review preoperative lab values carefully.
  • Follow neuraxial protocols for patients on anticoagulants.
  • Treatment may include steroids, anti-inflammatories, or surgical decompression in severe cases.

• Meningitis/Infection
  • May lead to neurological injury.
  • Strict sterile technique is essential to prevent this complication.
  • Treatment depends on the causative organism (antibiotics or antivirals).