Failed spinal anesthesia in a pregnant patient under a "Cash-Before-Care" operating room model in a low- and middle-income country: a systems-ethics case report.

Safe anesthesia for non-obstetric surgery during pregnancy requires access to emergency drugs and airway equipment should a primary technique fail or a complication occur. In Cameroon, the "cash-before-care" model requires patients to pre-purchase specific anesthetic kits, which can significantly constrain contingency planning. A 31-year-old woman (G4P3) at 18 + 4 weeks' gestation presented for urgent wound debridement. An initial spinal anesthetic (hyperbaric bupivacaine 10 mg, fentanyl 25 μg, morphine 100 μg) failed to produce any motor or sensory block after 15 min. Although conversion to general anesthesia was indicated, it was not possible because the family had purchased only the spinal kit. Following senior consultation, a second spinal attempt at a different interspace with a reduced bupivacaine dose proved successful. This case highlights how out-of-pocket procurement transforms intraoperative safety into a socioeconomic variable, where emergency rescue depends on household liquidity rather than immediate clinical necessity.