Editorial
Editorial
Limiting the dose of local anaesthetic for caesarean section under
spinal anaesthesia has the limbo bar been set too low?
Spinal anaesthesia for caesarean sec-
tion should ideally last the duration
of the procedure, without incurring
maternal or fetal adverse effects, but
striking a balance between reliability
and efcacy of subarachnoid block
and its adverse effects is, at times,
challenging.
A major consideration is spinal
anaesthesia-induced maternal hypo-
tension, which occurs in up to three
quarters of women in the absence of
prophylactic measures [1]. In addi-
tion to inducing maternal nausea
and vomiting, impaired uteroplacen-
tal perfusion can lead to fetal acida-
emia [2]. Strategies to avoid or limit
spinal-induced hypotension include:
giving intravenous uid; positioning
the mother; wrapping her legs; and
administering vasopressor drugs [2].
The frequency and degree of hypo-
tension is inuenced by the dose of
subarachnoid local anaesthetic [3] so
it is no surprise that the literature is
replete with studies using lower
doses than conventionally described
[4].
Caesarean section has been suc-
cessfully performed under spinal
anaesthesia established with hyper-
baric bupivacaine 2.5 mg, co-admin-
istered with an opioid [5]. Such a
technique has been variably termed
small-dose [6], low-dose [7], very
low-dose [8], ultra low-dose [9] or
Anaesthesia 2012 The Association of Anaesthetists of Great Britain and Ireland
ultra light spinal anaesthesia [5].
Dening the cut-off at which a dose
can be reasonably described as low is
not straightforward and begs the
question: What is a conventional
dose? The latter has changed, falling
over time from 12.515 mg [10], to
now 8 mg or more [11], but there is
no consensus, making study compar-
isons difcult [12]. Research has con-
tributed to our understanding of the
optimal dose of subarachnoid local
anaesthetic, by determination of its
ED50 and ED95 (effective dose in 50%
and 95% of patients, respectively)
when used with opioid for caesarean
section [13, 14]. Since the ED95 for
success, dened as lack of intra-
operative pain rather than attainment
of a specic thoracic dermatome
sensory block, can arguably be con-
sidered the dose associated with a 5%
rate of inadequate anaesthesia, it may
be more appropriate to dene a low
dose as one below this value that is,
for bupivacaine, less than 11 mg if
hyperbaric or 13 mg if isobaric [13,
14].
Low intrathecal local anaes-
thetic doses in a single-shot spinal
technique can be effective but are
problematic the intended advanta-
ges may be offset by the limited
means of extending the block should
initial distribution be unsatisfactory that this approach has signicant
and inability to maintain the block
Anaesthesia 2012, 67, 343354
should surgery be prolonged [4, 13].
Placement of an epidural catheter as
part of a combined spinal-epidural
(CSE) technique improves function-
ality, allowing the administration of
other neuraxial analgesic drugs and
prolongation of surgical anaesthesia
if required [4, 12, 15]. Modications
of the original CSE technique include
epidural volume extension (EVE),
in which a dose of spinal bupivacaine
below the ED95 is administered [4].
Satisfactory sensory block is achieved
largely by enhancing the cephalad
movement of intrathecal drug by
compressing the lumbar cerebrospi-
nal uid compartment with a bolus
of epidural saline, injected shortly
after the subarachnoid drugs. Low-
dose sequential CSE shares similari-
ties but is based on incremental
doses of epidural local anaesthetic
given at a variable time after the
subarachnoid drugs, typically when
satisfactory block distribution has
not been achieved [4]. These modi-
cations were introduced with the
aim of reducing the incidence of
spinal-induced hypotension, while
preserving the ability to augment or
extend the sensory block before or
during surgery [3].
Proponents of low-dose spinal
anaesthesia with bupivacaine argue
advantages over a conventional-dose
347
Anaesthesia 2012, 67, 343354
technique, principally less maternal
hypotension but also greater mater-
nal satisfaction, due to reduced
motor block of shorter duration [3,
4, 6, 9]. Studies investigating low-
dose CSE anaesthesia (with or with-
out EVE) differ widely in their
methodology, including the drugs,
doses, volume of solution, nature
and timing of epidural bolus injec-
tions and the method by which
adequate sensory block is dened
or assessed. Although often associ-
ated with less maternal hypotension
[3, 9, 11, 16], this is not always the
case [6, 17]. A meta-analysis pub-
lished in 2011, dening conven-
tional-dose as > 8 mg bupivacaine
(which many would consider a low
cut-off value), explored the efcacy
of low- versus high-dose spinal
bupivacaine for caesarean section
[11]. Low-dose spinal anaesthesia
was associated with a lower risk
(22% reduction) of hypotension
(RR 0.78, 95% CI 0.650.93) but
because of considerable clinical and
methodological heterogeneity, the
quality of evidence supporting a
reduction in hypotension (variably
dened across the 12 studies analy-
sed) was only of moderate quality.
This also applied to a reduction in
maternal nausea and
or vomiting. No study of different
spinal doses has shown a difference
in neonatal outcome.
Can other techniques achieve
comparable haemodynamic stability,
without restricting the dose of spinal
bupivacaine? Spinal-induced hypo-
tension is more effectively managed
with alpha-agonists (e.g. phenyleph-
rine and metaraminol) than with
ephedrine [18, 19], yet almost all
studies of low-dose spinal anaesthe-
348
sia used ephedrine to prevent or treat
hypotension. With uid co-hydra-
tion and a prophylactic phenyleph-
rine infusion, hypotension can be
very infrequent despite the use of
conventional-dose bupivacaine (10
12.5 mg) [20].
Are there down-sides to low-
dose techniques? Most prospective
studies concluding that a low-dose
technique did not compromise
anaesthetic efcacy had this as a
secondary outcome, basing sample
size on a primary outcome of the
incidence of hypotension or a differ-
ence in sensory level, not intra-oper-
ative pain [3, 6, 9, 16]. High-grade
evidence indicates that the risk of
intra-operative pain during caesarean
section performed under a low-dose
spinal anaesthetic is increased [11,
17, 21]. Low-dose versus conven-
tional-dose techniques are associated
with a clinically relevant increase in
need for analgesic supplementation
during surgery (RR 3.76, 95% CI
2.385.92) [11]. Put another way,
approximately one additional patient
will experience intra-operative pain
requiring treatment for every four
patients receiving a low-dose
( 8 mg bupivacaine) technique.
Exclusion of some studies from the
meta-analysis has been criticised [12]
and the ndings may have changed
had a different dose cut-off been
chosen, although proponents of
low-dose techniques usually advocate
bupivacaine 7 mg or less [15]. This
value approximates the ED50 of bup-
ivacaine [13, 14, 22], a dose only
likely to work well for half the
obstetric population. We consider
completely effective spinal anaesthe-
sia (i.e. no intra-operative pain) for
9099% a more desirable aim.
Anaesthesia 2012 The Association of Anaesthetists of Great Britain and Ireland
Editorial
It can be argued that the quality
of anaesthesia produced by a low-
dose spinal block is equal to that
based on larger doses, but of shorter
duration, making an increased like-
lihood of block supplementation a
predictable feature [12]. Provided a
CSE technique is used, the epidural
catheter can be used to not only treat
intra-operative pain, but to avoid
pain if surgery is delayed in onset or
prolonged. The option of such a pre-
emptive strike has been recom-
mended 45 minutes after the start
of the CSE anaesthetic if the uterus is
not closed [15]. This dual utility of
the epidural catheter complicates the
denition of block failure in some
studies, because an epidural top-up
may be used as a deliberate compo-
nent of the technique rather than
due to a failure of the technique [12].
The meta-analysis excluded studies
with mixed interventions (epidural
and spinal drug administration), the
authors arguing that inclusion would
fail to isolate differences in the
efcacy of the intrathecal component
[11]. Given the increased risk of
intra-operative pain and block sup-
plementation, we support the opin-
ion that catheter-based techniques
are integral to the optimal clinical
application of low-dose spinal anaes-
thesia [4].
Intra-operative pain is unpleas-
ant, sometimes distressing, and car-
ries risk for both the patient and the
anaesthetist. Irrespective of manage-
ment and depending on its severity,
timing and response to interventions,
pain may necessitate conversion to
general anaesthesia. Studies of low-
dose spinal anaesthesia have not been
adequately powered to investigate
this infrequent event, but if intra-
Editorial
operative pain is more common, it
may be that general anaesthesia is
also more likely, creating an obvious
concern. Pain experienced during
caesarean section performed under
neuraxial block is a common reason
for complaint and litigation in obstet-
ric anaesthetic practice [23]. Data
held by the NHS Litigation Authority
on negligence claims relating to
regional anaesthesia in England show
a relatively large proportion are asso-
ciated with such pain and that these
claims are often damaging [24].
Impeccable management of anaes-
thesia and pain does not guarantee
the anaesthetist immunity. Neverthe-
less, assessment and documentation
of an adequate block before incision
is a fundamental clinical and medi-
colegal standard of care [23]. The
appropriate extent of block and the
optimal sensory modality for assess-
ment are widely debated. There is a
consistent difference in the dermato-
mal block of cold, light touch and
pinprick, with tests of light touch
demonstrating the least variability
[25]. It has been suggested that, when
using 0.5% hyperbaric bupivacaine
with diamorphine, a block to touch
involving T6 is likely to provide pain-
free conditions [26]. Since cephalad
extension and probably block density
are inuenced by the spinal local
anaesthetic dose, is this reliably
achievable with a low-dose tech-
nique? Not all studies specify the
method of block assessment and
there is heterogeneity for both the
sensation assessed and the dermato-
mal distribution deemed adequate for
surgery. Patients under low-dose CSE
may show no demonstrable block to
touch, despite a loss of cold to T3
[27], but this does not appear to
Anaesthesia 2012 The Association of Anaesthetists of Great Britain and Ireland
relate to the incidence of pain, sug-
gesting that block to cold at or above
T3 may be a more reliable indicator
of satisfactory anaesthesia when low-
dose spinals are used [27]. This lack
of clarity regarding the best modality
of testing and desirable dermatomal
level for different spinal techniques
may have medicolegal implications.
Some units and clinicians rou-
tinely use a low-dose technique for
caesarean section, with undoubtedly
good results [15]. With experience,
these anaesthetists have mastered the
technique and recognise when a pro-
phylactic epidural bolus is advisable
[12]. However, low-dose spinals are
unsuitable in some units, particularly
those in which delays frequently
occur between establishment of block
and commencement of surgery or
where operating times longer than
45 minutes are the norm. Low-dose
techniques also appear less reliable
than conventional-dose techniques in
less experienced hands [7], and
despite the security of an epidural
catheter, epidural drugs are not usu-
ally clinically effective in less than
10 minutes. Even in an institution
where low-dose CSE was the pre-
ferred approach, and despite using
the same dose of hyperbaric bupiva-
caine (mean 6.3 mg), both intra-
operative pain (incidence 49%) and
maternal hypotension were signi-
cantly increased in the hands of
anaesthetists with limited training in
low-dose techniques compared to
their colleagues who had undergone
intensive training [7]. Of note, intra-
operative pain was experienced by
13% of patients cared for by inten-
sively trained anaesthetists, an inci-
dence higher than that reported in
other prospective studies (5%) and
Anaesthesia 2012, 67, 343354
audits (6%) from units using a
conventional-dose method [28, 29].
Are there specic circumstances
where low-dose spinal techniques are
clearly advantageous? Several case
reports describe the successful use
of a low-dose CSE technique for
caesarean section for women consid-
ered at serious risk of harm from
haemodynamic instability, such as
those with cardiomyopathy, aortic
stenosis, pulmonary hypertension
and pre-eclampsia [8, 30]. In the
absence of randomised controlled
trials, the safety and efcacy of this
technique compared with alternatives
in these specic patients is unknown,
but expert opinion supports the value
of considering such an approach,
despite uncertainty over the detail,
including drug dosages.
In summary, a lower dose of
intrathecal local anaesthetic than
traditionally used (for example
< 8 mg) is likely to reduce the inci-
dence of spinal-induced hypotension
and possibly the severity of its con-
sequent maternal effects, at the
expense of a slower onset and shorter
duration of anaesthesia, an increased
risk of intra-operative pain, require-
ment for supplementation and pos-
sibly (unproven), conversion to
general anaesthesia. Yet to be sub-
stantiated are purported advantages
such as earlier postoperative ambu-
lation and greater maternal satisfac-
tion because of reduced motor block.
Low-dose spinal anaesthetic tech-
niques (as part of a CSE at least)
work well in most cases and in some
units are standard practice [15].
However, in the hands of clinicians
with less experience and in units in
which appropriate logistic condi-
tions, such as the immediate avail-
349
Anaesthesia 2012, 67, 343354
ability and preparedness of a surgeon
and the low likelihood of complex
or prolonged surgery, cannot be
guaranteed, the increased risk of
intra-operative pain is concerning.
Injection of local anaesthetic with
opioid in a dose close to the ED95
has stood the test of time with
respect to quality and reliability for
caesarean section. With appropriate
pharmacological therapy, modest
intravenous uid administration
and appropriate maternal position-
ing, none of which are usually
contraindicated, clinically relevant
hypotension can be made a very
infrequent event without compro-
mising the efcacy of the block.
So, how low can you go? With
the back-up of an epidural catheter
and a number of caveats applied, the
experienced anaesthetist may nd a
low-dose spinal anaesthetic tech-
nique, using bupivacaine 2.5 to
7.5 mg, a valuable approach. How-
ever, this technique should not be
undertaken without previous train-
ing and due reection, because in a
number of circumstances it may
prove a poor choice. We can choose
to go low like the limbo dancer, but
with respect to our duty of care to
our patient, we must do our best to
not dislodge the bar.
Competing interests
No external funding and no compet-
ing interests declared.
M. W. M. Rucklidge
Consultant Anaesthetist
Royal Devon and Exeter Hospital
Exeter, UK
Email: matthew.rucklidge@nhs.net
M. J. Paech
Professor of Anaesthesia
School of Medicine and
350
Pharmacology, University of Western
Australia and
Department of Anaesthesia and Pain
Medicine
King Edward Memorial Hospital for
Women
Perth, Australia
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Editorial
EVAR fever: minimally invasive, maximally inclusive?
Open repair of abdominal and tho-
racic aortic aneurysm inevitably in-
volves clamping and unclamping of
this major vessel and, consequently,
major haemodynamic perturbation.
Experienced vascular anaesthetists
and good teamwork can ameliorate
the peaks and troughs of blood
pressure and heart rate with appro-
priate use of vasoactive drugs, uid
therapy and anaesthesia itself. Such
levels of prociency can only be
reached by thorough training and
experience, both in volume and
quality. In recent times, endovascu-
lar aneurysm repair (EVAR) has
revolutionised vascular surgery such
that this technique has markedly
surpassed that of open repair in
most centres, heralding a change in
the professional landscapes for both
surgeons and anaesthetists. Similar
to performing laparoscopic proce-
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M, Lyons G. Sensory testing of spinal
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ferential block and variability. Interna-
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2010; 19: 2615.
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and touch for assessing the level of
spinal block at caesarean section. Inter-
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27. Walters MA, Van de Velde M. Testing the
block for caesarean section leaving
touch out in the cold. International
Journal of Obstetric Anesthesia 2011;
20: S6.
28. Sng BL, Lim Y, Sia AT. An observational
prospective cohort study of incidence
dures, surgeons are required to cre-
ate three dimensional experiences
from two dimension information, a
skill that is vastly different to that
required for open repair. Anaesthe-
tists are still exposed to patients with
signicant co-morbidities attendant
with vascular disease and, since the
surgical trauma is markedly reduced,
many patients who would not be
considered able to tolerate the stress
of open surgery are now being
offered EVAR. What, then, are the
implications of this developmental
shift?
It would be prudent rst to
consider the current status of EVAR
within the realm of aneurysmal sur-
gery. Recent publications of large
trials comparing open versus endo-
vascular repair have produced a
rather similar message: EVAR pro-
vides an early survival advantage
Anaesthesia 2012, 67, 343354
and characteristics of failed spinal anaes-
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29. Kinsella SM. A prospective audit of
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30. Hamlyn EL, Douglass CA, Plaat F, Crow-
hurst JA, Stocks GM. Low-dose sequen-
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tion in patients with significant cardiac
disease. International Journal of Obstet-
ric Anesthesia 2005; 14: 35561.
doi: 10.1111/j.1365-2044.2012.07104.x
over open repair, but this benet is
eroded over time so that equivalence
is evident by around the two-year
mark [13]. Endovascular aneurysm
repair is now recommended as a
treatment for unruptured infrarenal
aortic aneurysm by the National
Institute for Health and Clinical
Excellence, although the same body
provided conicting results for cost
effectiveness of this approach for
each quality adjusted life year [4].
The need for a suitable landing zone
proximal to the aneurysm for graft
deployment represents an evolution-
ary obstacle that currently prevents
EVAR from taking over from the
open procedure entirely. However,
with improved training and technol-
ogy such as branched and fenestrated
devices, and the use of hybrid pro-
cedures requiring extra-anatomical
arterial anastomoses, increasingly
351