{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,21]],"date-time":"2026-08-21T14:35:39Z","timestamp":1787322939678,"version":"build-2736575974"},"reference-count":11,"publisher":"Oxford University Press (OUP)","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"abstract":"ABSTRACT<\/jats:title>\n \n Introduction<\/jats:title>\n Neuraxial anesthesia with hyperbaric bupivacaine is the gold standard anesthetic for cesarean delivery (CD), yet bupivacaine spinal failure rates have been reported as high as 25.3% and often occur in unexplained clusters. Our military treatment facility (MTF) has informally tracked batch-associated failures since 2019, but established a formal tracking system in 2024. This project aimed to identify supply-chain and storage factors contributing to bupivacaine failures, reduce the overall failure rate to &lt;4%, and reduce general anesthetics (GA) attributed to failed spinals to zero percent within 3\u00a0years.<\/jats:p>\n <\/jats:sec>\n \n Materials and Methods<\/jats:title>\n This quality improvement project was given research-exempt status by the Brooke Army Medical Center Human Research Protections Office, reference number 996159. Using sequential Plan-Do-Study-Act cycles, we established a departmental failure-reporting system, provided departmental education on the risks of failure, replaced any bupivacaine lot after two failures, changed manufacturers, and reviewed transport and storage with Logistics and the Defense Health Agency\u2019s Medical Material Quality Control system. Pyxis and operating room temperatures were measured directly. After the 12th failure, bupivacaine vials were relocated from the pyxis to a room temperature wall-unit lock box.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n From January 2024 to June 2026, 19 failures occurred among an estimated 960 vials, for an overall failure rate of 2.0%. Bupivacaine stored in the pyxis or spinal kits failed at a rate of 3.9% (13\/336, 95% CI, 2.3-6.5) versus 1.0% (6\/624, 95% CI, 0.4-2.1) when stored in a room temperature lock box. Annual failure rates fell from 3.6% in 2024 (10\/274, 95% CI, 2-6.6) to 0.9% in 2026 (2\/230, 95% CI, 0.2-3.1). GAs attributed to a failed spinal dropped from 37.5% in 2024 (6\/16, 95% CI, 18.5-61.4) to 0.0% in 2026 (0\/23, 95% CI, 0-14.3). The most significant drop in GA rates attributed to failed spinal occurred after relocating the bupivacaine vials from the pyxis to the wall unit lock box: 19.4% (6\/31, 95% CI, 9.2-36.3) to 2.5% (1\/40, 95% CI, 0.4-12.9). The temperature log revealed the rear pyxis pocket averaged 76.0\u00b0F but exceeded the maximum recommended storage temperature of 77.0\u00b0F on 13 occasions.<\/jats:p>\n <\/jats:sec>\n \n Conclusions<\/jats:title>\n Controlled, monitored bupivacaine storage paired with a simple reporting pathway to identify cluster failures was associated with a clinically meaningful reduction in spinal failures and failed-spinal GAs for CD. The intervention is low-cost, sustainable, and has external validity for all MTFs storing bupivacaine. It is relevant to deployed settings where temperature control is challenging, and where spinal anesthetics offer superior anesthesia with minimal resources. Limitations include concurrent interventions, annual bupivacaine use for determining failure rates was estimated, and few events occurred. Future work could add continuous temperature logging and multi-site collaboration.<\/jats:p>\n <\/jats:sec>","DOI":"10.1093\/milmed\/usag401","type":"journal-article","created":{"date-parts":[[2026,8,14]],"date-time":"2026-08-14T11:16:31Z","timestamp":1786706191000},"source":"Crossref","is-referenced-by-count":0,"title":["Exploring Military Logistics and Storage Systems to Decrease the Rate of Failed Bupivacaine Spinals for Cesarean Delivery: A Quality Improvement Project"],"prefix":"10.1093","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-2583-7993","authenticated-orcid":false,"given":"Trevor","family":"Tuthill","sequence":"first","affiliation":[{"name":"David Grant Medical Center , Travis Air Force Base, CA 94535,","place":["United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Brandin","family":"Moreland","sequence":"additional","affiliation":[{"name":"Brooke Army Medical Center , Ft. Sam Houston, TX 78234,","place":["United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0005-6867-4188","authenticated-orcid":false,"given":"Courtney","family":"Hood","sequence":"additional","affiliation":[{"name":"Brooke Army Medical Center , Ft. Sam Houston, TX 78234,","place":["United States"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2026,8,21]]},"reference":[{"key":"2026082109344320500_usag401-B1","doi-asserted-by":"publisher","first-page":"598","DOI":"10.1111\/anae.15657","article-title":"Inadequate neuraxial anaesthesia in patients undergoing elective caesarean section: a systematic review","volume":"77","author":"Patel","year":"2022","journal-title":"Anaesthesia"},{"key":"2026082109344320500_usag401-B2","doi-asserted-by":"publisher","first-page":"430","DOI":"10.1213\/ANE.0000000000006459","article-title":"The incidence and predictors of failed spinal anesthesia after intrathecal injection of local anesthetic for cesarean delivery: a single-center, 9-year retrospective review","volume":"138","author":"Jin","year":"2024","journal-title":"Anesth Analg"},{"key":"2026082109344320500_usag401-B3","doi-asserted-by":"publisher","first-page":"3000605251403364","DOI":"10.1177\/03000605251403364","article-title":"Contributors to failed spinal anesthesia","volume":"54","author":"Zegeye","year":"2026","journal-title":"J Int Med Res"},{"key":"2026082109344320500_usag401-B4","first-page":"1360","article-title":"Failed spinal anesthesia with hyperbaric bupivacaine","volume":"82","author":"Laudani","year":"2016","journal-title":"Minerva Anestesiol"},{"key":"2026082109344320500_usag401-B5","doi-asserted-by":"publisher","first-page":"803","DOI":"10.1007\/s12630-019-01343-6","article-title":"Investigation into spinal anesthetic failure with hyperbaric bupivacaine: the role of cold exposure on bupivacaine degradation","volume":"66","author":"Wasan","year":"2019","journal-title":"Can J Anaesth"},{"key":"2026082109344320500_usag401-B6"},{"key":"2026082109344320500_usag401-B7","doi-asserted-by":"publisher","first-page":"e19","DOI":"10.1213\/ANE.0000000000004304","article-title":"Factors associated with failure of spinal anesthetic: an 8-year retrospective analysis of patients undergoing elective hip and knee joint arthroplasty","volume":"130","author":"Colish","year":"2020","journal-title":"Anesth Analg"},{"key":"2026082109344320500_usag401-B8","doi-asserted-by":"publisher","first-page":"272","DOI":"10.1213\/01.ANE.0000184252.16045.0E","article-title":"The influence of hyperbaric bupivacaine temperature on the spread of spinal anesthesia","volume":"102","author":"Arai","year":"2006","journal-title":"Anesth Analg"},{"key":"2026082109344320500_usag401-B9","doi-asserted-by":"publisher","first-page":"132687","DOI":"10.1155\/2014\/132687","article-title":"The effects on sensorial block, motor block, and haemodynamics of levobupivacaine at different temperatures applied in the subarachnoid space","volume":"2014","author":"Nazli","year":"2014","journal-title":"BioMed Res Int"},{"key":"2026082109344320500_usag401-B10","doi-asserted-by":"publisher","first-page":"352","DOI":"10.1093\/bja\/77.3.352","article-title":"Acid-base state of cerebrospinal fluid during pregnancy and its effect on spread of spinal anaesthesia","volume":"77","author":"Hirabayashi","year":"1996","journal-title":"Br J Anaesth"},{"key":"2026082109344320500_usag401-B11","doi-asserted-by":"publisher","first-page":"59","DOI":"10.1136\/rapm-2023-105229","article-title":"Crystallization of mixtures of local anesthetics with and without select adjuvants: a semiquantitative light microscopy analysis","volume":"50","author":"Hoerner","year":"2025","journal-title":"Reg Anesth Pain Med"}],"container-title":["Military Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/academic.oup.com\/milmed\/advance-article-pdf\/doi\/10.1093\/milmed\/usag401\/70754884\/usag401.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/milmed\/advance-article-pdf\/doi\/10.1093\/milmed\/usag401\/70754884\/usag401.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,21]],"date-time":"2026-08-21T13:34:47Z","timestamp":1787319287000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/milmed\/advance-article\/doi\/10.1093\/milmed\/usag401\/8767732"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,8,21]]},"references-count":11,"URL":"https:\/\/doi.org\/10.1093\/milmed\/usag401","relation":{},"ISSN":["0026-4075","1930-613X"],"issn-type":[{"value":"0026-4075","type":"print"},{"value":"1930-613X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8,21]]},"article-number":"usag401"}}