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Total Spinal — FRCA Final MCQ

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HardObstetric AnaesthesiaTotal SpinalFRCA Final

A 45-year-old woman (ASA II) develops a total spinal after an intended epidural top-up with 20 mL of 0.1% bupivacaine containing fentanyl 2 micrograms/mL for labour analgesia. She becomes unconscious and apnoeic. Her arterial pressure is 60/30 mmHg, her heart rate is 35 beats/min in sinus rhythm, and her carotid pulse is weak. Despite tracheal intubation, ventilation with 100% oxygen, left uterine displacement and a rapid intravenous fluid bolus, the cardiovascular collapse persists. Which is the most appropriate immediate vasopressor treatment?

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Correct answer: C — Adrenaline 50 micrograms intravenously

The correct answer is C. This is bradycardic, peri-arrest cardiovascular collapse from extensive sympathetic blockade, not uncomplicated post-neuraxial hypotension. A titrated intravenous adrenaline bolus provides alpha-mediated vasoconstriction and beta-1 support of heart rate and contractility; 50 micrograms lies within the UK QRH emergency range of 10–100 micrograms. Phenylephrine is appropriate for routine obstetric spinal hypotension when cardiac output and heart rate are adequate, but its pure alpha effect may aggravate bradycardia. Metaraminol is also predominantly vasoconstrictor, while ephedrine is less reliable in profound collapse. A noradrenaline infusion may be useful for ongoing support but should not delay an immediately effective rescue bolus.

Reference: Royal College of Anaesthetists/Association of Anaesthetists, Quick Reference Handbook, section 2-4: Hypotension, current RCoA-hosted edition. https://www.rcoa.ac.uk/media/9386