Regional Anesthetic Complications Vgc07

Regional Anesthetic Regional Anesthetic ComplicationsComplications

Vincent Conte, MDVincent Conte, MDAssociate Clinical ProfessorAssociate Clinical ProfessorNurse Anesthesia ProgramNurse Anesthesia Program

FIU College of Nursing and Health FIU College of Nursing and Health SciencesSciences

RA ComplicationsRA Complications

Presentation divided into two Presentation divided into two sections:sections:

1)1) ContraindicationsContraindications

2)2) Complications (both Spinal & Complications (both Spinal & Epidural)Epidural)

AssessmentAssessment

If a neuraxial anesthetic is being considered, If a neuraxial anesthetic is being considered, the risks and benefits need to be discussed the risks and benefits need to be discussed with the patientwith the patient

An INFORMED CONSENT needs to be obtained An INFORMED CONSENT needs to be obtained prior to performing any neuraxial anestheticprior to performing any neuraxial anesthetic

A careful H & P and PE need to be done to A careful H & P and PE need to be done to make sure there are no CONTRAINDICATIONS make sure there are no CONTRAINDICATIONS to performing a neuraxial anestheticto performing a neuraxial anesthetic

AssessmentAssessment

Patients should understand prior to their Patients should understand prior to their block, that once the block is performed block, that once the block is performed they will have little or no motor function they will have little or no motor function until the effects of the block wears offuntil the effects of the block wears off

Patients should also be warned that Patients should also be warned that once the block takes effect, they may once the block takes effect, they may feel like their limbs are in various feel like their limbs are in various positions (straight up, bent or folded, positions (straight up, bent or folded, etc.) but are really still and flat against etc.) but are really still and flat against the bed or any rests or padding that you the bed or any rests or padding that you provideprovide

Physical ExamPhysical Exam

Prior to ANY Spinal or Epidural Prior to ANY Spinal or Epidural anesthetic, a CAREFUL examination anesthetic, a CAREFUL examination of the back should be made. Things of the back should be made. Things to look for are:to look for are:

Surgical ScarsSurgical Scars

ScoliosisScoliosis

Skin lesionsSkin lesions

Palpable Spinous ProcessesPalpable Spinous Processes

Physical ExamPhysical Exam

Although no preoperative screening Although no preoperative screening tests are required for healthy tests are required for healthy patients undergoing neuraxial patients undergoing neuraxial blockade, coagulation studies and blockade, coagulation studies and platelet count should be checked platelet count should be checked when clinical history suggests the when clinical history suggests the possibility of a bleeding diasthesispossibility of a bleeding diasthesis

ContraindicationsContraindications

There are certain ABSOLUTE There are certain ABSOLUTE contraindications to Regional contraindications to Regional Anesthesia:Anesthesia:

1)1) Infection at the site:Infection at the site:

Could theoretically pre-dispose Could theoretically pre-dispose patients to hematogenous spread of patients to hematogenous spread of the infectious agents into the the infectious agents into the epidural or subarachnoid spaceepidural or subarachnoid space


2) 2) Patient Refusal:Patient Refusal: Any denial by the Any denial by the patient should end there and then; patient should end there and then; DO NOT continue to try to convince a DO NOT continue to try to convince a patient for regional anesthesia unless patient for regional anesthesia unless you have a valid medical reason to you have a valid medical reason to persist; even then a NO is a NO!!!! persist; even then a NO is a NO!!!! Just make sure you document that Just make sure you document that the “patient was offered a regional the “patient was offered a regional and risks/benefits were explained, and risks/benefits were explained, but patient refused”but patient refused”


3) 3) Coagulopathy or other Bleeding Coagulopathy or other Bleeding Diasthesis:Diasthesis: Do I really need to Do I really need to explain why not in these explain why not in these circumstances????circumstances????

(Just Kidding) If they can’t clot then (Just Kidding) If they can’t clot then you stick the minimum number of you stick the minimum number of needles into a patient (hopefully just needles into a patient (hopefully just an IV and that is it!!)an IV and that is it!!)


4) 4) Severe Hypovolemia:Severe Hypovolemia: Any Any sympathectomy will compound the sympathectomy will compound the hypotension TREMENDOUSLYhypotension TREMENDOUSLY

5) 5) Increased Intracranial Pressure:Increased Intracranial Pressure: Any increase can lead to a brain Any increase can lead to a brain stem herniation if a spinal is stem herniation if a spinal is performed and even a minute performed and even a minute amount of CSF is lostamount of CSF is lost


6) 6) Severe Aortic Stenosis:Severe Aortic Stenosis: Any Any change in SVR or preload and change in SVR or preload and hypovolemia can result in SEVERE hypovolemia can result in SEVERE myocardial ischemia and Sudden myocardial ischemia and Sudden Cardiac Death; NOT GOODCardiac Death; NOT GOOD

7) 7) Severe Mitral Stenosis:Severe Mitral Stenosis: Any Any change in SVR can lead to sudden change in SVR can lead to sudden Right Heart failure and rapid onset of Right Heart failure and rapid onset of Pulmonary edemaPulmonary edema

Relative Relative ContraindicationsContraindications

Relative Contraindications are:Relative Contraindications are:

1) 1) Systemic Sepsis:Systemic Sepsis: For the same reason For the same reason as an infection at the site, if bacteremia as an infection at the site, if bacteremia exists, it can be possible to seed the CNS exists, it can be possible to seed the CNS during your procedure (For me, it’s a NO during your procedure (For me, it’s a NO GO) Also, systemic sepsis is usually GO) Also, systemic sepsis is usually accompanied by Relative Hypovolemia accompanied by Relative Hypovolemia (peripheral vasodilation) which can (peripheral vasodilation) which can become much worse with an added drop become much worse with an added drop in SVR from your blockin SVR from your block


2) 2) An Uncooperative Patient:An Uncooperative Patient: Regional anesthesia requires at least Regional anesthesia requires at least some degree of patient cooperation. some degree of patient cooperation. This may be difficult or impossible for This may be difficult or impossible for patients with dementia, psychosis, or patients with dementia, psychosis, or emotional instability (MOST OF emotional instability (MOST OF YOU!!!)YOU!!!)


3) 3) Preexisting Neurological Preexisting Neurological Deficits:Deficits: Patients with preexisting Patients with preexisting neurological deficits may report that neurological deficits may report that their symptoms are worse following a their symptoms are worse following a block (Usually through their block (Usually through their Lawyer!!) It may be impossible to Lawyer!!) It may be impossible to discern effects or complications of discern effects or complications of the block from preexisting deficits or the block from preexisting deficits or unrelated exacerbation of preexisting unrelated exacerbation of preexisting diseasedisease


3) Careful documentation is a MUST in any 3) Careful documentation is a MUST in any patient with preexisting neurological patient with preexisting neurological deficits and documentation of an deficits and documentation of an explanation of risks/benefits and possible explanation of risks/benefits and possible worsening of symptoms is worsening of symptoms is MANDATORY!!!!! (To me, another NO GO)MANDATORY!!!!! (To me, another NO GO)

This is a major source of liability This is a major source of liability connected with the use neuraxial connected with the use neuraxial blockade blockade


4) 4) Stenotic Valvular Heart Lesions:Stenotic Valvular Heart Lesions: The The management of any valvular heart lesion management of any valvular heart lesion suggests minimal to moderate decreases in suggests minimal to moderate decreases in SVR (encourage forward flow) and keeping SVR (encourage forward flow) and keeping the heart rate normal to slightly decreased the heart rate normal to slightly decreased (to allow more filling times). The use of (to allow more filling times). The use of Regional Anesthesia can accomplish a Regional Anesthesia can accomplish a reduction in SVR but you will usually have a reduction in SVR but you will usually have a compensatory rise in heart rate and compensatory rise in heart rate and sometimes the drop in SVR can be very sometimes the drop in SVR can be very precipitousprecipitous


4) 4) Stenotic Valvular Lesions Stenotic Valvular Lesions (cont’d):(cont’d): In light of these possible In light of these possible complications, IF the use of a Regional complications, IF the use of a Regional Anesthetic is planned, it may be more Anesthetic is planned, it may be more prudent to use an Epidural and prudent to use an Epidural and SLOWLY titrate the level of surgical SLOWLY titrate the level of surgical anesthesia via the catheter to anesthesia via the catheter to minimize the drop in SVR with minimize the drop in SVR with compensatory increase in heart ratecompensatory increase in heart rate


4) 4) Stenotic Lesions (cont’d):Stenotic Lesions (cont’d): The The presence of any valvular heart lesions presence of any valvular heart lesions requires a consultation with requires a consultation with Cardiology (if time permits) but most Cardiology (if time permits) but most experts recommend AVOIDING a experts recommend AVOIDING a regional anesthetic in the face of regional anesthetic in the face of SYMPTOMATIC Stenotic lesions, and to SYMPTOMATIC Stenotic lesions, and to USE WITH CAUTION in any stenotic USE WITH CAUTION in any stenotic lesions that are ASYMPTOMATIC and lesions that are ASYMPTOMATIC and use an Epidural rather than a spinal use an Epidural rather than a spinal and take your time to titrate the level and take your time to titrate the level of anesthetic neededof anesthetic needed


5) 5) Severe Spinal Deformity:Severe Spinal Deformity: Many Many anesthetists feel that in the face of anesthetists feel that in the face of severe scoliosis or spinal deformity, severe scoliosis or spinal deformity, the spread of local anesthetic may be the spread of local anesthetic may be altered to such an extent that a high altered to such an extent that a high spinal can easily be obtained, or that spinal can easily be obtained, or that adequate surgical anesthesia may not adequate surgical anesthesia may not be able to be accomplished due to the be able to be accomplished due to the abnormal spread and distribution abnormal spread and distribution secondary to the deformity (My rule is secondary to the deformity (My rule is that if it looks real funky and twisted, that if it looks real funky and twisted, it is a NO GO)it is a NO GO)

Controversial Controversial ContraindicationsContraindications

1)1) Prior surgery at the site of injection:Prior surgery at the site of injection: After back surgery, the anatomy can be After back surgery, the anatomy can be altered tremendously and you may loose altered tremendously and you may loose the ability to find the epidural space. The the ability to find the epidural space. The spread of your local anesthetic can be spread of your local anesthetic can be altered to a large extent and render your altered to a large extent and render your anesthetic uselessanesthetic useless

(My rule is if surgery has been at one level, (My rule is if surgery has been at one level, you can do a spinal at a level below BUT an you can do a spinal at a level below BUT an Epidural will probably fail or end up in a Epidural will probably fail or end up in a Dural Puncture and is a NO GO; if multiple Dural Puncture and is a NO GO; if multiple levels have been worked on, it is a NO GO levels have been worked on, it is a NO GO from the start because the anatomy will be from the start because the anatomy will be too abnormal, even for a spinal) too abnormal, even for a spinal)


2) 2) Inability to communicate with the Inability to communicate with the patient:patient: With dementia, previous stroke with With dementia, previous stroke with loss of speech, or with any psychiatric loss of speech, or with any psychiatric condition that makes communication difficult condition that makes communication difficult or impossible, you cannot assess the presence or impossible, you cannot assess the presence of any signs and symptoms of intravascular of any signs and symptoms of intravascular injection or high spinal so if you DO use a injection or high spinal so if you DO use a Regional anesthetic on these patients, you Regional anesthetic on these patients, you must be VERY CAREFUL about watching your must be VERY CAREFUL about watching your patient for vital sign changes that may indicate patient for vital sign changes that may indicate adverse reactionsadverse reactions


3) 3) Complicated Surgery:Complicated Surgery: With any With any complicated surgery, several factors complicated surgery, several factors may make a Regional NOT the best may make a Regional NOT the best choice.choice.

a) Possible long (>3 hours) surgery a) Possible long (>3 hours) surgery can become very uncomfortable for can become very uncomfortable for the patient and require increasing the patient and require increasing levels of sedation that may levels of sedation that may compromise respiratory functioncompromise respiratory function


3) b) If the possibility of major blood 3) b) If the possibility of major blood loss exists, your potential drop in loss exists, your potential drop in SVR from your regional can be SVR from your regional can be compounded to a severe level. It’s compounded to a severe level. It’s also a pain in the $#@ to have to also a pain in the $#@ to have to worry about a semi-awake patient worry about a semi-awake patient when you are busy transfusing, when you are busy transfusing, especially if you need to manage the especially if you need to manage the patient’s airway even just slightlypatient’s airway even just slightly


3) c) If the surgery involves maneuvers that 3) c) If the surgery involves maneuvers that can compromise respirations (position, high can compromise respirations (position, high level, pressure on diaphragm) it can be level, pressure on diaphragm) it can be enough to send your patient into respiratory enough to send your patient into respiratory failure if their respiratory function is even failure if their respiratory function is even slightly compromised by your Regional slightly compromised by your Regional anesthetic (PLUS, it is very uncomfortable anesthetic (PLUS, it is very uncomfortable for the patient to feel like they can’t breathe; for the patient to feel like they can’t breathe; you’ll need a lot of sedation and that will you’ll need a lot of sedation and that will probably only make the situation worse)probably only make the situation worse)

Neuraxial Blockade in the Neuraxial Blockade in the Setting of Anticoagulants & Setting of Anticoagulants &

Antiplatelet AgentsAntiplatelet Agents1) 1) Oral Anticoagulants (Coumadin):Oral Anticoagulants (Coumadin): ANY ANY

patient on Coumadin, even if given just a patient on Coumadin, even if given just a few doses in-hospital, needs a PT AND INR few doses in-hospital, needs a PT AND INR prior to surgery (and they need to be prior to surgery (and they need to be normal!!!) Coumadin should be d/c’ed at normal!!!) Coumadin should be d/c’ed at best a week and at a minimum 5 days prior best a week and at a minimum 5 days prior to surgery and an INR of >1.5 is a to surgery and an INR of >1.5 is a CONTRAINDICATION to using a block; <1.5, CONTRAINDICATION to using a block; <1.5, proceed with caution (use spinal rather than proceed with caution (use spinal rather than epidural)epidural)

Antiplatelet DrugsAntiplatelet Drugs

2) 2) ASA and other NSAID’s:ASA and other NSAID’s: By themselves By themselves do not appear to increase the risk of spinal do not appear to increase the risk of spinal or epidural hematomas in regional or epidural hematomas in regional anesthesia. However, if the patient is on anesthesia. However, if the patient is on chronic therapy or has been taking them for chronic therapy or has been taking them for more that 2 weeks, a PFT should be more that 2 weeks, a PFT should be obtained prior to performing a regional obtained prior to performing a regional anesthetic. Daily baby ASA is safe and can anesthetic. Daily baby ASA is safe and can be continued throughout surgery and post-be continued throughout surgery and post-op, but chronic NSAID therapy should be op, but chronic NSAID therapy should be d/c’ed at least 3 days prior to surgery and d/c’ed at least 3 days prior to surgery and usually 5-7 days is bestusually 5-7 days is best


2) 2) Plavix and other related drugs:Plavix and other related drugs: These These drugs are very potent and are an ABSOLUTE drugs are very potent and are an ABSOLUTE contraindication to regional anesthesia. contraindication to regional anesthesia. They need to be d/c’ed for AT LEAST 7 days They need to be d/c’ed for AT LEAST 7 days with Plavix, 14 days with Ticlid and 48 hours with Plavix, 14 days with Ticlid and 48 hours with Rheopro. All patients on the above with Rheopro. All patients on the above medications need a PFT prior to performing medications need a PFT prior to performing any regional anesthetic, even if they have any regional anesthetic, even if they have d/c’ed meds for the recommended time d/c’ed meds for the recommended time periods or longerperiods or longer

Standard HeparinStandard Heparin

3) 3) Standard Heparin (unfractionated): Standard Heparin (unfractionated): Minidose subQ heparin is NOT a Minidose subQ heparin is NOT a contraindication to neuraxial blockade. On contraindication to neuraxial blockade. On patients who are receiving Heparin infusion, patients who are receiving Heparin infusion, the Heparin needs to be d/c’ed for at least 4 the Heparin needs to be d/c’ed for at least 4 hours prior to block and a normal PTT needs hours prior to block and a normal PTT needs to be documented prior to performing your to be documented prior to performing your block. If the patient is currently on a Heparin block. If the patient is currently on a Heparin infusion immediately preoperatively, then a infusion immediately preoperatively, then a regional anesthetic is CONTRAINDICATEDregional anesthetic is CONTRAINDICATED


3) 3) Standard Heparin (cont’d):Standard Heparin (cont’d): If an epidural cath is placed and then If an epidural cath is placed and then

the patient is heparinized, the cath the patient is heparinized, the cath cannot be removed until the heparin cannot be removed until the heparin is d/c’ed for at least 4 hours and a is d/c’ed for at least 4 hours and a normal PTT is documented. Also, if normal PTT is documented. Also, if bleeding is encountered during the bleeding is encountered during the block procedure, at least an hour block procedure, at least an hour should pass before the patient is should pass before the patient is heparinized.heparinized.

Low-Molecular Weight Low-Molecular Weight HeparinHeparin

4) 4) Lovenox:Lovenox: If blood or bleeding occurs during If blood or bleeding occurs during your block, Lovenox administration should be your block, Lovenox administration should be delayed for at least 24 hours post procedure. delayed for at least 24 hours post procedure. If an epidural cath is in place, it should be If an epidural cath is in place, it should be removed AT LEAST 2 hours prior to removed AT LEAST 2 hours prior to administration of the first dose of Lovenox. If administration of the first dose of Lovenox. If given while a cath IS in place, it cannot be given while a cath IS in place, it cannot be removed for at least 10 hrs. following the last removed for at least 10 hrs. following the last dose, and the next dose cannot be given for dose, and the next dose cannot be given for at least 2 hours AFTER removal of the cathat least 2 hours AFTER removal of the cath

Fibrinolytic/Thrombolytic Fibrinolytic/Thrombolytic TherapyTherapy

5) 5) Fibrinolytic/Thrombolytic Fibrinolytic/Thrombolytic Therapy:Therapy: Is an ABSOLUTE Is an ABSOLUTE contraindication to regional contraindication to regional anesthesia and needs to be d/c’ed anesthesia and needs to be d/c’ed for at least 3 days prior to performing for at least 3 days prior to performing a block. COMPLETE clotting studies a block. COMPLETE clotting studies need to be done and documented need to be done and documented NORMAL prior to initiating your block NORMAL prior to initiating your block (PT, PTT, INR, PFT, Platelet Count)(PT, PTT, INR, PFT, Platelet Count)

SHORT BreakSHORT Break

TimeTime

(stretch)(stretch)

ComplicationsComplications

The complications of Epidural, Spinal The complications of Epidural, Spinal and Caudal anesthetics range from and Caudal anesthetics range from bothersome to the crippling and life-bothersome to the crippling and life-threateningthreatening

Broadly, the complications can be Broadly, the complications can be thought of as resulting from thought of as resulting from exaggerated physiologic side effects, exaggerated physiologic side effects, placement of the needle, and drug placement of the needle, and drug toxicitytoxicity


A very large study of regional A very large study of regional anesthetics from France provides an anesthetics from France provides an indication of the relatively low indication of the relatively low incidence of serious complicationsincidence of serious complications

In contrast, the ASA Closed Claim In contrast, the ASA Closed Claim project helps identify the most project helps identify the most common causes of LIABILITY claims common causes of LIABILITY claims involving Anesthetic complications in involving Anesthetic complications in the OR settingthe OR setting


In a 20 year period (1980-1999) In a 20 year period (1980-1999) regional anesthesia accounted for regional anesthesia accounted for 18%18% of ALL liability claims. The of ALL liability claims. The claims were broken down by:claims were broken down by:

1)1) Temporary or Non-disabling (11.5%)Temporary or Non-disabling (11.5%)2)2) Serious injuries (death – 2.3%; Serious injuries (death – 2.3%;

permanent nerve injury – 1.8%; permanent nerve injury – 1.8%; permanent brain damage – 1.4% and permanent brain damage – 1.4% and other permanent injuries – 0.72%)other permanent injuries – 0.72%)


Lumbar EPIDURAL anesthesia accounted for Lumbar EPIDURAL anesthesia accounted for 42% of all cases42% of all cases

Spinal anesthesia accounted for 34% of all Spinal anesthesia accounted for 34% of all casescases

Caudal anesthesia was utilized in only 2% of Caudal anesthesia was utilized in only 2% of all casesall cases

ALL types had their complications occur ALL types had their complications occur mostly in Obstetric patients (this reflects mostly in Obstetric patients (this reflects the higher percentage of use of regional the higher percentage of use of regional anesthesia in these patients; 68%)anesthesia in these patients; 68%)

ComplicationsComplications In the French study, the percentages were In the French study, the percentages were

MUCH lowerMUCH lower Out of 40,640 patients who had SPINALS, Out of 40,640 patients who had SPINALS,

0.00006%0.00006% suffered cardiac arrests, suffered cardiac arrests, 0.0001%0.0001% died, died, 0.00004%0.00004% had permanent had permanent nerve injurynerve injury

Out of 30,413 patients who had EPIDURALS, Out of 30,413 patients who had EPIDURALS, 0.00009%0.00009% had cardiac arrests, had cardiac arrests, 0%0% died died and and 0.0001%0.0001% suffered permanent nerve suffered permanent nerve injury injury

(The French have to ALWAYS be better than (The French have to ALWAYS be better than the Americans in everything!!!)the Americans in everything!!!)

Exaggerated Physiologic Exaggerated Physiologic Side EffectsSide Effects

These are:These are:1)1) HypotensionHypotension2)2) BradycardiaBradycardia3)3) High Neural BlockHigh Neural Block4)4) Total SpinalTotal Spinal5)5) Cardiac Arrest during SpinalCardiac Arrest during Spinal6)6) Urinary RetentionUrinary Retention7)7) NauseaNausea8)8) HypoventilationHypoventilation

HypotensionHypotension

Hypotension is estimated to occur in about Hypotension is estimated to occur in about 1/3 of patients receiving spinal anesthesia 1/3 of patients receiving spinal anesthesia and in about 1/5 of all patients receiving and in about 1/5 of all patients receiving epiduralsepidurals

The hypotension results from sympathetic The hypotension results from sympathetic nervous system blockade that:nervous system blockade that:

a) Decreases venous return to the heart a) Decreases venous return to the heart and that decreases cardiac outputand that decreases cardiac output

b) Decreases Systemic Vascular b) Decreases Systemic Vascular Resistance (SVR)Resistance (SVR)

HypotensionHypotension

Modest decreases in blood pressure are Modest decreases in blood pressure are most likely from a drop in SVRmost likely from a drop in SVR

Large drops in blood pressure are from Large drops in blood pressure are from BOTH a drop in SVR & Cardiac OutputBOTH a drop in SVR & Cardiac Output

The degree of hypotension often The degree of hypotension often parallels the level of spinal anesthesia parallels the level of spinal anesthesia and the intravascular fluid volume of and the intravascular fluid volume of the patientthe patient

With hypovolemia, the extent of With hypovolemia, the extent of hypotension can be markedly increased hypotension can be markedly increased

Hypotension - TreatmentHypotension - Treatment

Is treated physiologically by restoration Is treated physiologically by restoration of venous return so as to increase of venous return so as to increase cardiac outputcardiac output

Head down position (restore volume)Head down position (restore volume) Volume administration (increase Volume administration (increase

preload)preload) Pharmacologic correction of decreased Pharmacologic correction of decreased

SVR (Neo) and drop in cardiac output SVR (Neo) and drop in cardiac output (Ephedrine)(Ephedrine)

Hypotension-TreatmentHypotension-Treatment BE CAREFUL not to OVER-hydrate BE CAREFUL not to OVER-hydrate

patients who may be at risk for heart patients who may be at risk for heart failure from fluid overloadfailure from fluid overload

These are elderly patients, patients These are elderly patients, patients with ischemic heart disease or a with ischemic heart disease or a history of any type of valvular heart history of any type of valvular heart disease, patients with a history of disease, patients with a history of Congestive Heart FailureCongestive Heart Failure

In these patients, a Neo drip may be In these patients, a Neo drip may be needed instead of very aggressive needed instead of very aggressive hydrationhydration

BradycardiaBradycardia Occurs in 10-15% of patients receiving Occurs in 10-15% of patients receiving

spinal anesthesiaspinal anesthesia Risk increases with increasing level of Risk increases with increasing level of

anesthesiaanesthesia Caused by block of cardioaccelerator fibers Caused by block of cardioaccelerator fibers

originating from T1-T4originating from T1-T4 Usually promptly responds to treatment Usually promptly responds to treatment

with Atropine 0.2-0.4mgwith Atropine 0.2-0.4mg There are reported cases of sudden There are reported cases of sudden

AsystoleAsystole in the absence of any obvious in the absence of any obvious preventable eventspreventable events

For Asystole, prompt intervention with For Asystole, prompt intervention with Epinephrine is usually necessary to correct Epinephrine is usually necessary to correct the problemthe problem

High Neural BlockadeHigh Neural Blockade

High levels of neural blockade can occur High levels of neural blockade can occur readily with either spinal or epidural readily with either spinal or epidural anesthesiaanesthesia

Causes are usually:Causes are usually:

1)1) Administration of an excessive doseAdministration of an excessive dose

2)2) Failure to reduce standard dose in selected Failure to reduce standard dose in selected patients (elderly, pregnant, obese or very patients (elderly, pregnant, obese or very short patients)short patients)

3)3) Unusual sensitivity or spread of local Unusual sensitivity or spread of local anestheticanesthetic


Spinal anesthesia ascending into the Spinal anesthesia ascending into the cervical levels causes SEVERE cervical levels causes SEVERE hypotension, bradycardia (blockade of hypotension, bradycardia (blockade of cardiac accelerator fibers) and cardiac accelerator fibers) and respiratory insufficiencyrespiratory insufficiency

Unconsciousness, apnea and Unconsciousness, apnea and hypotension resulting from high levels hypotension resulting from high levels of spinal anesthesia are referred to as of spinal anesthesia are referred to as a “High Spinal” or a “Total Spinal”a “High Spinal” or a “Total Spinal”


A High Spinal or Total Spinal can also A High Spinal or Total Spinal can also occur following an attempted occur following an attempted epidural/caudal if there is inadvertent epidural/caudal if there is inadvertent intrathecal injectionintrathecal injection

Sustained severe hypotension with a Sustained severe hypotension with a LOW block can also lead to apnea via LOW block can also lead to apnea via severe medullary hypoperfusionsevere medullary hypoperfusion


Symptoms of a High neural block Symptoms of a High neural block include dyspnea and numbness or include dyspnea and numbness or weakness in the upper extremitiesweakness in the upper extremities

Nausea w or w/o vomiting usually Nausea w or w/o vomiting usually occurs and precedes the development occurs and precedes the development of hypotensionof hypotension

This may continue to develop into This may continue to develop into severe hypotension, bradycardia and severe hypotension, bradycardia and respiratory insufficiency or total apnearespiratory insufficiency or total apnea


Treatment of a high block or total Treatment of a high block or total spinal include supplemental oxygen spinal include supplemental oxygen and maintaining an adequate airway and maintaining an adequate airway (from a simple chin lift to placement (from a simple chin lift to placement of an ETT)of an ETT)

Treatment also involves support of Treatment also involves support of circulation with volume, head down circulation with volume, head down position and vasopressors (see position and vasopressors (see treatment of hypotension)treatment of hypotension)


If conventional methods do not work with If conventional methods do not work with the hypotension, then an Epi drip and the hypotension, then an Epi drip and boluses may be neededboluses may be needed

Bradycardia should be treated promptly Bradycardia should be treated promptly with Atropine and/or Epi with Atropine and/or Epi

If respiratory and hemodynamic control If respiratory and hemodynamic control can be maintained, surgery may proceedcan be maintained, surgery may proceed

If vital signs remain unstable despite If vital signs remain unstable despite aggressive treatment, then surgery should aggressive treatment, then surgery should be cancelled and the patient sent to an be cancelled and the patient sent to an ICU bed as soon as they are stabilizedICU bed as soon as they are stabilized

Cardiac ArrestCardiac Arrest

Large Prospective studies report a Large Prospective studies report a relatively high incidence of cardiac relatively high incidence of cardiac arrest in patients having a spinal arrest in patients having a spinal anesthetic (1:1500)anesthetic (1:1500)

Many of the arrests were preceded by Many of the arrests were preceded by episodes of sudden bradycardia and episodes of sudden bradycardia and occurred in young healthy patients occurred in young healthy patients with a low resting heart rate with a low resting heart rate preoperativelypreoperatively

Cardiac ArrestCardiac Arrest

A recent study recognized strong vagal A recent study recognized strong vagal responses and decreased preload as responses and decreased preload as key factors in development of CAkey factors in development of CA

To prevent this occurrence, any patient To prevent this occurrence, any patient with a low resting heart rate with a low resting heart rate preoperatively should be treated with preoperatively should be treated with prophylactic volume expansion and prophylactic volume expansion and PROMPT treatment of bradycardia with PROMPT treatment of bradycardia with Atropine, pressors or Epi as neededAtropine, pressors or Epi as needed

Urinary RetentionUrinary Retention Spinal Anesthesia blocks the S2-S4 root Spinal Anesthesia blocks the S2-S4 root

fibers decreasing urinary bladder tone and fibers decreasing urinary bladder tone and inhibits the voiding reflexinhibits the voiding reflex

This may require catheterization to relieve This may require catheterization to relieve distensiondistension

The bladder paralysis is time dependent The bladder paralysis is time dependent and as the LA wears off, the normal and as the LA wears off, the normal bladder tone and voiding reflex should bladder tone and voiding reflex should returnreturn

There are rare instances in which the LA There are rare instances in which the LA has worn off, yet the bladder still gets has worn off, yet the bladder still gets distended and requires catheterizationdistended and requires catheterization

Urinary RetentionUrinary Retention

These patients may have to be admitted These patients may have to be admitted overnight and usually an indwelling foley overnight and usually an indwelling foley is placed until the bladder regains toneis placed until the bladder regains tone

No Out-patient receiving neuraxial block No Out-patient receiving neuraxial block should be discharged until the patient can should be discharged until the patient can void voluntarilyvoid voluntarily

Also, if bladder dysfunction persists even Also, if bladder dysfunction persists even after the block has worn off, this may be a after the block has worn off, this may be a manifestation of serious neural injury manifestation of serious neural injury secondary to the performance of the blocksecondary to the performance of the block

At that point a Neurology Consultation At that point a Neurology Consultation may be in ordermay be in order

NauseaNausea

Nausea occurring shortly after Nausea occurring shortly after initiation of a spinal anesthetic must initiation of a spinal anesthetic must alert the Anesthetist to the possible alert the Anesthetist to the possible presence of hypotension sufficient to presence of hypotension sufficient to cause cerebral ischemiacause cerebral ischemia

Treatment of the hypotension should Treatment of the hypotension should also treat the nausea (see also treat the nausea (see Hypotension)Hypotension)

NauseaNausea

Another cause of nausea during a Another cause of nausea during a spinal anesthetic is a predominance spinal anesthetic is a predominance of parasympathetic stimulation of the of parasympathetic stimulation of the GI tract (Sympathetics are blocked)GI tract (Sympathetics are blocked)

Treatment with Atropine (0.2-0.4mg) Treatment with Atropine (0.2-0.4mg) may be effective therapy (blocking may be effective therapy (blocking muscarinic effects)muscarinic effects)

Zofran or Anzimet may also be used Zofran or Anzimet may also be used instead of Atropineinstead of Atropine

HypoventilationHypoventilation

Exaggerated hypoventilation may Exaggerated hypoventilation may accompany IV administration of drugs accompany IV administration of drugs intended to produce sedation during the intended to produce sedation during the planned procedureplanned procedure

It is believed to be from an enhanced It is believed to be from an enhanced effect of the drugs due to the sympathetic effect of the drugs due to the sympathetic nervous system blockadenervous system blockade

Vigilance and attention to your patient and Vigilance and attention to your patient and monitors will help you discover this rare monitors will help you discover this rare complication if it ever occurscomplication if it ever occurs

Complications Associated Complications Associated with Needle or Catheter with Needle or Catheter

InsertionInsertion The following can be caused by needle or The following can be caused by needle or catheter insertion:catheter insertion:

1)1) Inadequate Anesthesia or AnalgesiaInadequate Anesthesia or Analgesia2)2) Intravascular InjectionIntravascular Injection3)3) Subdural InjectionSubdural Injection4)4) BackacheBackache5)5) Postdural Puncture HeadachePostdural Puncture Headache6)6) Neurological Injury/Transient Radicular Neurological Injury/Transient Radicular

IrritationIrritation7)7) Spinal or Epidural HematomasSpinal or Epidural Hematomas8)8) Meningitis or ArachnoiditisMeningitis or Arachnoiditis9)9) Epidural AbscessEpidural Abscess10)10) Sheering of an Epidural CatheterSheering of an Epidural Catheter

Inadequate Spinal Inadequate Spinal AnesthesiaAnesthesia

All neuraxial blocks are “blind” techniques All neuraxial blocks are “blind” techniques and as such will always have a failure rate and as such will always have a failure rate associated with themassociated with them

The failure rate is commonly inversely The failure rate is commonly inversely proportional to the clinician’s experienceproportional to the clinician’s experience

Even with the endpoint of spinal Even with the endpoint of spinal anesthesia being free flow of CSF, failure anesthesia being free flow of CSF, failure can still occur secondary to needle can still occur secondary to needle movement during injection, incomplete movement during injection, incomplete entry of needle opening into the SAS, entry of needle opening into the SAS, (aspirate before AND after injection) or (aspirate before AND after injection) or loss of potency of LA due to ageloss of potency of LA due to age

Inadequate Epidural Inadequate Epidural AnesthesiaAnesthesia

Unlike Spinal anesthesia with its Unlike Spinal anesthesia with its defined endpoint (clear flow of CSF), defined endpoint (clear flow of CSF), Epidural anesthesia is dependent on Epidural anesthesia is dependent on detection of a subjective LOR and detection of a subjective LOR and variable anatomy of the epidural variable anatomy of the epidural space and less predictable spread of space and less predictable spread of LALA


Misplaced injections can occur in a Misplaced injections can occur in a number of situations:number of situations:

1)1) False LOR is obtained in soft, pliable spinal False LOR is obtained in soft, pliable spinal ligaments found in young patientsligaments found in young patients

2)2) Para-spinous muscle injections with a Para-spinous muscle injections with a misplaced off-center injection can misplaced off-center injection can simulate LORsimulate LOR

3)3) Your injection can go subdural or Your injection can go subdural or intravascular instead of into the epidural intravascular instead of into the epidural spacespace


4) A unilateral block can occur if your 4) A unilateral block can occur if your catheter has either exited the epidural catheter has either exited the epidural space or coursed laterallyspace or coursed laterally

5) Segmental sparring or “Hot Spots” can 5) Segmental sparring or “Hot Spots” can occur as a result of septations or scar tissue occur as a result of septations or scar tissue from previous epiduralsfrom previous epidurals

6) Patients may complain of visceral pain 6) Patients may complain of visceral pain during lower abdominal procedures. This is during lower abdominal procedures. This is due to high level innervation of certain due to high level innervation of certain visceral structures and can usually be visceral structures and can usually be overcome by pushing your level a little overcome by pushing your level a little higher. Visceral fibers that travel with the higher. Visceral fibers that travel with the vagus nerve may also be responsible for vagus nerve may also be responsible for this, and only supplemental sedation can be this, and only supplemental sedation can be used to overcome thisused to overcome this

Intravascular InjectionIntravascular Injection

Inadvertent intravascular injection of Inadvertent intravascular injection of LA can produce very high serum levels LA can produce very high serum levels of LA’s very rapidlyof LA’s very rapidly

High levels in the CNS can cause High levels in the CNS can cause seizures and unconsciousnessseizures and unconsciousness

High levels in the Cardiovascular High levels in the Cardiovascular system can cause hypotension, system can cause hypotension, arrhythmias and eventual arrhythmias and eventual cardiovascular collapsecardiovascular collapse


Because the dosage of anesthetic is Because the dosage of anesthetic is so much smaller with a spinal, these so much smaller with a spinal, these complications rarely occur with a complications rarely occur with a spinal but are primarily seen with spinal but are primarily seen with epidurals and caudalsepidurals and caudals

LA can be injected directly into a vein LA can be injected directly into a vein by the needle or later through the by the needle or later through the catheter that has migrated into a catheter that has migrated into a blood vesselblood vessel


The incidence of intravascular The incidence of intravascular injection can be minimized by injection can be minimized by carefully ASPIRATING the needle or carefully ASPIRATING the needle or catheter BEFORE EVERY injection!!catheter BEFORE EVERY injection!!

Also, the incidence can be reduced Also, the incidence can be reduced by the use of a test dose with Epi to by the use of a test dose with Epi to see if you get a sudden increase in see if you get a sudden increase in heart rate heart rate


Severe side effects can also be Severe side effects can also be prevented by ALWAYS injecting meds prevented by ALWAYS injecting meds in increments of 3-5cc and waiting to in increments of 3-5cc and waiting to see if any side effects occur (ringing see if any side effects occur (ringing in ears, metallic taste in mouth, in ears, metallic taste in mouth, circumoral numbness, circumoral numbness, lightheadedness, SUDDEN weakness lightheadedness, SUDDEN weakness or numbness in legs)or numbness in legs)

Subdural InjectionSubdural Injection The SUBDURAL space (different from The SUBDURAL space (different from

the Subarachnoid space) is a potential the Subarachnoid space) is a potential space between the DURA and the space between the DURA and the ARACHNOID and extends intracranially ARACHNOID and extends intracranially so any LA injected into the subdural so any LA injected into the subdural space can produce much more serious space can produce much more serious complications than a high epidural cancomplications than a high epidural can

A subdural injection can mimic a Total A subdural injection can mimic a Total Spinal in its symptoms and physiologic Spinal in its symptoms and physiologic changeschanges

Subdural InjectionSubdural Injection

As with inadvertent IV injection, As with inadvertent IV injection, inadvertent subdural injection of LA during inadvertent subdural injection of LA during an EPIDURAL can become a disaster if not an EPIDURAL can become a disaster if not recognized in a timely fashionrecognized in a timely fashion

The clinical presentation is similar to that The clinical presentation is similar to that of a Total Spinal and the management is of a Total Spinal and the management is similar as wellsimilar as well

The exception is that the onset may be The exception is that the onset may be delayed for 15-30 minutes due to lower delayed for 15-30 minutes due to lower concentrations of agents usedconcentrations of agents used

Subdural InjectionSubdural Injection

Again, the incidence of this occurring Again, the incidence of this occurring can be reduced by incremental dosing can be reduced by incremental dosing and use of a test dose with epiand use of a test dose with epi

The symptoms will resemble those of The symptoms will resemble those of a subarachnoid injection of your a subarachnoid injection of your epidural anesthesia with sudden onset epidural anesthesia with sudden onset of numbness and weakness of the of numbness and weakness of the lower extremitieslower extremities

BackacheBackache As a needle passes through the skin, As a needle passes through the skin,

subq tissues, muscle and ligaments it subq tissues, muscle and ligaments it causes varying degrees of tissue traumacauses varying degrees of tissue trauma

A localized inflammatory response with A localized inflammatory response with or w/o muscle spasm may be or w/o muscle spasm may be responsible for the presentation of a responsible for the presentation of a postop backachepostop backache

The more difficult the procedure was will The more difficult the procedure was will also increase the chances of the patient also increase the chances of the patient experiencing a postop backacheexperiencing a postop backache

BackacheBackache

It should be noted that up to 25-30% of It should be noted that up to 25-30% of patients receiving GA ALONE also patients receiving GA ALONE also complain of a backache postopcomplain of a backache postop

If it does occur, the backache or If it does occur, the backache or soreness is usually mild and self-limitedsoreness is usually mild and self-limited

It can last for up to several weeks in It can last for up to several weeks in some cases depending again on how some cases depending again on how much trauma was done during the much trauma was done during the procedureprocedure

BackacheBackache

Treatment is usually initially with Treatment is usually initially with Acetaminophen and warm then cold Acetaminophen and warm then cold compressescompresses

If stronger treatment is needed, then If stronger treatment is needed, then NSAID’s can be added to the regimenNSAID’s can be added to the regimen

If PO intake is not possible at that If PO intake is not possible at that point, Cox2 Inhibitors IV (Toradol) point, Cox2 Inhibitors IV (Toradol) can be given for 2-3 days then can be given for 2-3 days then converted to PO when possibleconverted to PO when possible

BackacheBackache

In RARE cases Narcotics can be In RARE cases Narcotics can be prescribed if pain is severe or prescribed if pain is severe or unresponsive to other conventional unresponsive to other conventional treatment methodstreatment methods

If the backache persists despite treatment If the backache persists despite treatment or gets worse, then this may be a sign of or gets worse, then this may be a sign of a more serious complication occurring a more serious complication occurring and a Neurology consultation may be and a Neurology consultation may be warranted (abscess, hematoma, etc.)warranted (abscess, hematoma, etc.)

Post-Dural Puncture Post-Dural Puncture HeadacheHeadache

Characterized as frontal or occipitalCharacterized as frontal or occipital Hallmark FeatureHallmark Feature: Worsens with : Worsens with

postural changes such as sitting or postural changes such as sitting or standingstanding

Supine, pain usually resolves when Supine, pain usually resolves when lying FLATlying FLAT

Occasionally accompanied by Occasionally accompanied by Tinnitus and decreased hearingTinnitus and decreased hearing


A headache w/o postural changes IS A headache w/o postural changes IS NOT a Post-dural puncture headacheNOT a Post-dural puncture headache

Caused by decreased CSF pressures and Caused by decreased CSF pressures and resulting tension on meningeal vessels resulting tension on meningeal vessels and nerves as a result of leakage of CSF and nerves as a result of leakage of CSF through the needle’s hole in the durathrough the needle’s hole in the dura

Incidence decreases with increasing age Incidence decreases with increasing age and drops off rapidly over 55 years of and drops off rapidly over 55 years of ageage


Incidence can be decreased by:Incidence can be decreased by:

1)1) Using a rounded point needle (Sprotte Using a rounded point needle (Sprotte or Whitacre)or Whitacre)

2)2) The point of the needle used to The point of the needle used to puncture the dura is oriented puncture the dura is oriented PARALLEL rather than perpendicular to PARALLEL rather than perpendicular to the meningeal fibers (running up and the meningeal fibers (running up and down)down)

3)3) Using a small gauge needle (25g) Using a small gauge needle (25g)

Treatment of PDPHTreatment of PDPH

Initially with bed rest, analgesics and Initially with bed rest, analgesics and oral/IV hydrationoral/IV hydration

If headache persists after 24-48 hours, it is If headache persists after 24-48 hours, it is recommended to do a “Blood Patch” as recommended to do a “Blood Patch” as the next line of therapythe next line of therapy

Blood patch is done by injecting 10-20cc of Blood patch is done by injecting 10-20cc of the patient’s blood epidurally at or near the patient’s blood epidurally at or near the same interspace that the original the same interspace that the original spinal anesthetic or dural puncture was spinal anesthetic or dural puncture was performedperformed

Treatment of PDPHTreatment of PDPH Prompt relief of the headache occurs in Prompt relief of the headache occurs in

85% of patients that receive a blood 85% of patients that receive a blood patchpatch

Due to the blood “Sealing” the hole Due to the blood “Sealing” the hole and slowing or stopping the leak of CSFand slowing or stopping the leak of CSF

Of those patients who do not respond Of those patients who do not respond to the initial blood patch, 90% will to the initial blood patch, 90% will respond to a second blood patchrespond to a second blood patch

Most common side effects of blood Most common side effects of blood patch are backache and radicular pain; patch are backache and radicular pain; usually resolves within 24 hoursusually resolves within 24 hours

Treatment of PDPHTreatment of PDPH An alternate treatment is administration An alternate treatment is administration

of IV Caffeine sodium benzoate (500mg)of IV Caffeine sodium benzoate (500mg) It has been shown to be effective in It has been shown to be effective in

about 70% of patients with PDPHabout 70% of patients with PDPH A controversial treatment is to inject NS A controversial treatment is to inject NS

or blood through an epidural catheter if or blood through an epidural catheter if it had occurred as a result of an it had occurred as a result of an epidural, as a prophylactic measure epidural, as a prophylactic measure before taking out the catheterbefore taking out the catheter

No study has been done that shows if No study has been done that shows if NS or blood via the catheter works or NS or blood via the catheter works or notnot

Neurological InjuryNeurological Injury

Serious neurologic injury is a rare but Serious neurologic injury is a rare but widely feared complication of epidural widely feared complication of epidural and spinal anesthesiaand spinal anesthesia

Multiple large number studies have Multiple large number studies have shown that the incidence of neurologic shown that the incidence of neurologic injury occurs between 0.03 and 0.1% of injury occurs between 0.03 and 0.1% of all central neuraxial block patientsall central neuraxial block patients

Of note is that in most of these series, Of note is that in most of these series, the block was not proven to be the block was not proven to be causativecausative

Neurologic InjuryNeurologic Injury

Persistent paresthesias and limited Persistent paresthesias and limited motor weakness are the most motor weakness are the most common injuries, although common injuries, although paraplegia and diffuse injury to paraplegia and diffuse injury to cauda equina roots (cauda equina cauda equina roots (cauda equina syndrome) do occur, but rarelysyndrome) do occur, but rarely

There does seem to be a slightly There does seem to be a slightly higher rate of injury associated with higher rate of injury associated with Epidurals vs. Spinals and this is Epidurals vs. Spinals and this is thought to be due to the larger size thought to be due to the larger size of the needle used in Epiduralsof the needle used in Epidurals

Neurologic InjuryNeurologic Injury

Injury may result from:Injury may result from:

a) Direct needle trauma to the spinal a) Direct needle trauma to the spinal cord or spinal nervescord or spinal nerves

b) Spinal cord ischemiab) Spinal cord ischemia


Spinal cord injury can be avoided by Spinal cord injury can be avoided by performing your block below L1 in performing your block below L1 in adults and L3 in Pediatric patientsadults and L3 in Pediatric patients

Also, any persistent parasthesia Also, any persistent parasthesia during injection or catheter passage during injection or catheter passage should be dealt with by immediately should be dealt with by immediately stopping what you are doing and stopping what you are doing and withdrawing either the needle of cath withdrawing either the needle of cath a few cm and then try againa few cm and then try again


Direct injection into the spinal cord Direct injection into the spinal cord can cause paraplegiacan cause paraplegia

Damage to the Conus Medullaris may Damage to the Conus Medullaris may cause isolated sacral dysfunction with cause isolated sacral dysfunction with lower extremity muscle weakness and lower extremity muscle weakness and loss of bowel or bladder functionloss of bowel or bladder function

Needles can cause direct physical Needles can cause direct physical trauma to spinal nerve roots as welltrauma to spinal nerve roots as well


Although most neurologic Although most neurologic complications resolve spontaneously, complications resolve spontaneously, some become permanentsome become permanent

Most permanent deficits have been Most permanent deficits have been associated with parasthesias from associated with parasthesias from either needle or catheter that were either needle or catheter that were not dealt with appropriately not dealt with appropriately (withdrawing needle or catheter as (withdrawing needle or catheter as soon as it is established that the soon as it is established that the parasthesia is persisting)parasthesia is persisting)


Some studies have suggested that Some studies have suggested that multiple attempts of a difficult block multiple attempts of a difficult block raise the chance of needle trauma raise the chance of needle trauma significantly (Don’t be a hero!! If you significantly (Don’t be a hero!! If you can’t get the block after 2-3 tries, can’t get the block after 2-3 tries, call for help and another pair of call for help and another pair of hands!!)hands!!)

Neurological Injury: Spinal Neurological Injury: Spinal IschemiaIschemia

Spinal cord Ischemia usually occurs as Spinal cord Ischemia usually occurs as a result of Global systemic a result of Global systemic hypotension and with the additional hypotension and with the additional pressure being placed on the spinal pressure being placed on the spinal cord by the epidural anesthetic, a cord by the epidural anesthetic, a higher level of pressure is needed to higher level of pressure is needed to perfuse the spinal cord as a result of perfuse the spinal cord as a result of the external pressurethe external pressure

Treatment is prompt treatment of Treatment is prompt treatment of hypotensionhypotension

Neurological Injury: Neurological Injury: ObstetricsObstetrics

A few things to keep in mind when A few things to keep in mind when dealing with Obstetric patients:dealing with Obstetric patients:

33% of Obstetric patients have 33% of Obstetric patients have neurological injury W/O even neurological injury W/O even receiving a block; secondary to nerve receiving a block; secondary to nerve injury or sustained pressure on nerves injury or sustained pressure on nerves during normal or (more commonly) during normal or (more commonly) long periods of labor and deliverylong periods of labor and delivery


Postpartum deficits usually involve Postpartum deficits usually involve Lateral Femoral Cutaneous neuropathy Lateral Femoral Cutaneous neuropathy (weakness of legs and pain in both inner (weakness of legs and pain in both inner thighs), foot drop, and possibly thighs), foot drop, and possibly paraplegiaparaplegia

Again, these injuries occur even without Again, these injuries occur even without a block, so if any of these types of a block, so if any of these types of injuries are reported after a long labor injuries are reported after a long labor with an epidural, they are most with an epidural, they are most commonly from nerve trauma during commonly from nerve trauma during deliverydelivery


Get a Neurology consultation ASAP just in Get a Neurology consultation ASAP just in case, but the Neurologist will usually clear case, but the Neurologist will usually clear your block of any blame once the symptoms your block of any blame once the symptoms are disclosed and the patient is examinedare disclosed and the patient is examined

In most cases these injuries are self-limiting In most cases these injuries are self-limiting and will resolve within a week or two, so and will resolve within a week or two, so reassure your patient that what they are reassure your patient that what they are feeling is temporary and is secondary from feeling is temporary and is secondary from their labor and delivery and NOT your block their labor and delivery and NOT your block but don’t forget, DOCUMENT, DOCUMENT, but don’t forget, DOCUMENT, DOCUMENT, DOCUMENT!!!DOCUMENT!!!


If, however, their symptoms persist longer If, however, their symptoms persist longer than a few weeks, the OB doc will probably than a few weeks, the OB doc will probably send the patient to a neurologist and if send the patient to a neurologist and if there is the slightest chance that the there is the slightest chance that the symptoms are from your block, believe me symptoms are from your block, believe me the patient will get in touch with you so the patient will get in touch with you so fast it will make your head spinfast it will make your head spin

When the smell of money is in the air, When the smell of money is in the air, people tend to work very quickly and people tend to work very quickly and efficientlyefficiently

Transient Radicular Transient Radicular IrritationIrritation

Transient Radicular Irritation of the Transient Radicular Irritation of the Lumbosacral nerves manifests as Lumbosacral nerves manifests as moderate to severe pain in the lower moderate to severe pain in the lower back, buttocks, and posterior thighsback, buttocks, and posterior thighs

Usually appears within 24 hours AFTER Usually appears within 24 hours AFTER complete recovery from a Spinal complete recovery from a Spinal anestheticanesthetic

The delayed onset of pain reflects the The delayed onset of pain reflects the development of inflammation and development of inflammation and irritationirritation

Transient Radicular Transient Radicular IrritationIrritation

Full recovery usually occurs within 7 daysFull recovery usually occurs within 7 days Bupivicaine and Tetracaine are associated Bupivicaine and Tetracaine are associated

with a LOWER incidence of occurrencewith a LOWER incidence of occurrence Treatment revolves around the use of Treatment revolves around the use of

NSAIDS to decrease inflammationNSAIDS to decrease inflammation In rare cases, steroids may need to be In rare cases, steroids may need to be

administered PO to decrease the administered PO to decrease the inflammatory responseinflammatory response

Persistent pain may be due to infection or Persistent pain may be due to infection or abscess formation and then aggressive abscess formation and then aggressive treatment is necessary treatment is necessary

Spinal or Epidural Spinal or Epidural HematomaHematoma

Needle or catheter trauma to Needle or catheter trauma to epidural veins often causes minor epidural veins often causes minor bleeding in the spinal canal that is bleeding in the spinal canal that is usually benign and self-limitingusually benign and self-limiting

Unfortunately, sometimes the Unfortunately, sometimes the bleeding can lead to the formation of bleeding can lead to the formation of a significant hematoma (spinal or a significant hematoma (spinal or epidural)epidural)

Spinal/Epidural Spinal/Epidural HematomasHematomas

The incidence of such hematomas has The incidence of such hematomas has been estimated to be about 1:150,000 been estimated to be about 1:150,000 for epidurals and 1:220,000 for spinal for epidurals and 1:220,000 for spinal anestheticsanesthetics

The vast majority of reported cases The vast majority of reported cases have occurred in patients with have occurred in patients with abnormal coag numbers either abnormal coag numbers either secondary to disease or secondary to disease or pharmacologic therapiespharmacologic therapies

Spinal/Epidural Spinal/Epidural HematomasHematomas

It should be noted that some hematomas It should be noted that some hematomas have been associated with REMOVAL of an have been associated with REMOVAL of an epidural catheter as well as insertionepidural catheter as well as insertion

The hematomas result in a mass effect on The hematomas result in a mass effect on the spinal cord with anywhere from mild to the spinal cord with anywhere from mild to severe symptomssevere symptoms

Unless the condition is diagnosed rapidly Unless the condition is diagnosed rapidly and appropriate treatment is instituted as and appropriate treatment is instituted as soon as possible, permanent neurologic soon as possible, permanent neurologic injury can occur injury can occur

Spinal/Epidural Spinal/Epidural HematomaHematoma

Symptoms typically appear suddenly Symptoms typically appear suddenly and include sharp back pain and leg and include sharp back pain and leg pain with a progression to numbness, pain with a progression to numbness, motor weakness and sphincter motor weakness and sphincter dysfunctiondysfunction

MRI or CT must be obtained as soon MRI or CT must be obtained as soon as the possibility of a hematoma is as the possibility of a hematoma is considered as well as a Neurology considered as well as a Neurology consultation ASAPconsultation ASAP

Spinal/Epidural Spinal/Epidural HematomaHematoma

In many cases good neurological recovery In many cases good neurological recovery has occurred in patients who have has occurred in patients who have undergone surgical decompression within 8-undergone surgical decompression within 8-12 hours (and needless to say that their 12 hours (and needless to say that their anesthesia bill is wiped clean and their #$@anesthesia bill is wiped clean and their #$@% is kissed thoroughly) % is kissed thoroughly)

To prevent its occurrence, Neuraxial To prevent its occurrence, Neuraxial anesthesia should be avoided in any patient anesthesia should be avoided in any patient with coagulopathies, significant with coagulopathies, significant thrombocytopenia (<80-100,000), platelet thrombocytopenia (<80-100,000), platelet dysfunction or those who have received dysfunction or those who have received fibrinolytic/thrombolytic therapy within 5 fibrinolytic/thrombolytic therapy within 5 days of possibly receiving a blockdays of possibly receiving a block

Meningitis & Meningitis & ArachnoiditisArachnoiditis

Infection of the Subarachnoid or Epidural Infection of the Subarachnoid or Epidural space can follow neuraxial blocks as the space can follow neuraxial blocks as the result of contamination of the equipment result of contamination of the equipment or injected solutions or as a result of or injected solutions or as a result of organisms tracked in from the skinorganisms tracked in from the skin

Indwelling catheters can become Indwelling catheters can become infected and track deep along the infected and track deep along the catheter’s pathcatheter’s path

Although possible, thankfully these are Although possible, thankfully these are rare complicationsrare complications

Meningitis & Meningitis & ArachnoiditisArachnoiditis

Another rarely reported complication is Another rarely reported complication is ArachnoiditisArachnoiditis

It can be either infectious or non-infectiousIt can be either infectious or non-infectious Clinically, signs are pain and other Clinically, signs are pain and other

neurological symptoms and an MRI/CT neurological symptoms and an MRI/CT scan will show CLUMPING of nerve rootsscan will show CLUMPING of nerve roots

It is often seen following epidural steroid It is often seen following epidural steroid injections but most commonly seen after injections but most commonly seen after spinal surgery or traumaspinal surgery or trauma

Epidural AbscessEpidural Abscess

Epidural abscess (EA) is a rare but Epidural abscess (EA) is a rare but devastating complication of neuraxial devastating complication of neuraxial anesthesiaanesthesia

The incidence varies widely from The incidence varies widely from 1:6500 to 1:500,000 epidurals 1:6500 to 1:500,000 epidurals depending on which study you look atdepending on which study you look at

EA can even occur in patients who EA can even occur in patients who never received a neuraxial block never received a neuraxial block (systemic spread)(systemic spread)


Most anesthesia cases are associated Most anesthesia cases are associated with the use of an Epidural catheterwith the use of an Epidural catheter

A hallmark of EA is the long delay in A hallmark of EA is the long delay in appearance of symptoms; one study appearance of symptoms; one study showed a mean period of 5 days showed a mean period of 5 days from insertion to symptomsfrom insertion to symptoms

Sometimes presentation can be Sometimes presentation can be delayed for weeksdelayed for weeks


Initially symptoms usually appear as Initially symptoms usually appear as back or vertebral pain which worsens back or vertebral pain which worsens during percussion over the spineduring percussion over the spine

Next, nerve root or radicular pain Next, nerve root or radicular pain usually developsusually develops

This is usually followed by motor and This is usually followed by motor and sensory deficits and sphincter sensory deficits and sphincter dysfunctiondysfunction

The final stage is usually paraplegia or The final stage is usually paraplegia or paralysis paralysis


Prognosis is associated with the Prognosis is associated with the degree of neurological dysfunction at degree of neurological dysfunction at the time of diagnosisthe time of diagnosis

Back pain and fever should alert the Back pain and fever should alert the clinician to the possibility of an EAclinician to the possibility of an EA

Once EA is suspected, if a catheter is Once EA is suspected, if a catheter is in place it needs to be removed ASAP in place it needs to be removed ASAP and MRI/CT scan needs to be and MRI/CT scan needs to be obtained right awayobtained right away


The catheter tip should be cultured and The catheter tip should be cultured and the insertion hole should be expressed the insertion hole should be expressed to see if any pus is present. This should to see if any pus is present. This should be cultured as wellbe cultured as well

IV antibiotic therapy should be IV antibiotic therapy should be instituted after cultures are obtained instituted after cultures are obtained and an Infectious Disease consult and an Infectious Disease consult ordered at onceordered at once

Neurosurgical consultation should also Neurosurgical consultation should also be obtained ASAPbe obtained ASAP


Treatment usually involves surgical Treatment usually involves surgical drainage and decompression drainage and decompression especially if neurologic deficits existespecially if neurologic deficits exist

There are very few reports of patients There are very few reports of patients recovering by the use of antibiotics recovering by the use of antibiotics alonealone

Measures to prevent it include minimal Measures to prevent it include minimal catheter manipulation and removal of catheter manipulation and removal of any catheter after a maximum of 96 any catheter after a maximum of 96 hours in placehours in place

Sheering of an Epidural Sheering of an Epidural CatheterCatheter

This is always a risk with any This is always a risk with any catheter through needle techniquecatheter through needle technique

It can happen especially if the It can happen especially if the epidural catheter is pulled BACK epidural catheter is pulled BACK through the needle after its insertionthrough the needle after its insertion

If for some reason a catheter gets If for some reason a catheter gets stuck during insertion then the stuck during insertion then the catheter and needle must be catheter and needle must be withdrawn together as a unit and a withdrawn together as a unit and a new catheter placed from the startnew catheter placed from the start


If a catheter breaks of or sheers off If a catheter breaks of or sheers off deep within the epidural space, deep within the epidural space, experts suggest leaving it alone and experts suggest leaving it alone and carefully observing the patientcarefully observing the patient

If the breakage occurs in the subQ If the breakage occurs in the subQ tissue, particularly if part of the tissue, particularly if part of the catheter is visible, it should be catheter is visible, it should be removed right away either manually removed right away either manually or surgicallyor surgically


In studies following patients with In studies following patients with sheered catheters in place, long term sheered catheters in place, long term complications are rare and most can complications are rare and most can continue on without any complications continue on without any complications or problemsor problems

However, in a small number of patients, However, in a small number of patients, the catheter causes an immune reaction the catheter causes an immune reaction that can mimic an Epidural Abscess and that can mimic an Epidural Abscess and then has to be removed surgically then has to be removed surgically

Sheered CatheterSheered Catheter

Basically, if it happens, get a baseline Basically, if it happens, get a baseline Neurologic Consultation which will probably Neurologic Consultation which will probably include an MRI/CT Scan and INFORM the include an MRI/CT Scan and INFORM the patient of the complication. A neurosurgical patient of the complication. A neurosurgical consult isn’t a bad idea either. DOCUMENT, consult isn’t a bad idea either. DOCUMENT, DOCUMENT, DOCUMENTDOCUMENT, DOCUMENT

Tell the patient that the vast majority of the Tell the patient that the vast majority of the people that this happens to go on and never people that this happens to go on and never have a problem for the rest of their lives have a problem for the rest of their lives BUT ALSO tell them that a very small BUT ALSO tell them that a very small percentage DO develop symptoms that may percentage DO develop symptoms that may need further medical attentionneed further medical attention

Sheered CatheterSheered Catheter

Tell them the symptoms that they may Tell them the symptoms that they may feel can range from back pain to having feel can range from back pain to having weakness or numbness in their legs and weakness or numbness in their legs and that if any symptoms develop that that if any symptoms develop that persist for longer than 2-3 days, to call persist for longer than 2-3 days, to call immediately and NOT to delay callingimmediately and NOT to delay calling

Give them a phone number to call that Give them a phone number to call that WILL be available even if you are not!!WILL be available even if you are not!!

Missing TipMissing Tip

Just as an aside that is semi-related to a Just as an aside that is semi-related to a Sheered Cath, whenever you are called to Sheered Cath, whenever you are called to REMOVE an epidural catheter, ALWAYS REMOVE an epidural catheter, ALWAYS look at the tip when it is removed and look at the tip when it is removed and DOCUMENT that the tip was seenDOCUMENT that the tip was seen

The tip is a THICK line that makes the tip The tip is a THICK line that makes the tip of the catheter black, so always make sure of the catheter black, so always make sure you see it and if you you see it and if you don’t,don’t, then then DOCUMENT and contact the person who DOCUMENT and contact the person who put it in and SAVE, SAVE, SAVE the cath in put it in and SAVE, SAVE, SAVE the cath in a bag or a glove to show the person who a bag or a glove to show the person who put it in because they probably won’t put it in because they probably won’t believe you when you tell thembelieve you when you tell them

Complications Associated Complications Associated with Drug Toxicitywith Drug Toxicity

There are three different clinical There are three different clinical situations that can arise from direct situations that can arise from direct toxicity of the LA’s:toxicity of the LA’s:

1)1) Systemic ToxicitySystemic Toxicity

2)2) Transient Neurological SymptomsTransient Neurological Symptoms

3)3) Lidocaine Neurotoxicity (Cauda Lidocaine Neurotoxicity (Cauda Equina Syndrome)Equina Syndrome)

Systemic ToxicitySystemic Toxicity

Systemic toxicity occurs when there is Systemic toxicity occurs when there is absorption of excessive amounts of LA’s absorption of excessive amounts of LA’s which produces high, toxic serum levelswhich produces high, toxic serum levels

Excessive absorption from epidural or Excessive absorption from epidural or caudal blocks is very rare, especially if caudal blocks is very rare, especially if the dose used is within the the dose used is within the recommended guidelines of dosage per recommended guidelines of dosage per kilogramkilogram

It is much more commonly caused by It is much more commonly caused by direct intravascular injection (which was direct intravascular injection (which was previously discussed)previously discussed)

Transient Neurological Transient Neurological SymptomsSymptoms

Transient Neurological Symptoms was Transient Neurological Symptoms was first described in 1993first described in 1993

It is also referred to as Transient It is also referred to as Transient Radicular Irritation and is characterized Radicular Irritation and is characterized by back pain radiating to the legs W/O by back pain radiating to the legs W/O sensory or motor deficitsensory or motor deficit

The symptoms characteristically occur The symptoms characteristically occur AFTER the block has worn off and AFTER the block has worn off and resolves spontaneously within a few resolves spontaneously within a few daysdays


It is most commonly associated with It is most commonly associated with hyperbaric Lidocaine (11.9%), hyperbaric Lidocaine (11.9%), Tetracaine ( 1.6%), Bupivicaine Tetracaine ( 1.6%), Bupivicaine ( 1.3%) ( 1.3%)

There are also case reports of TNS There are also case reports of TNS following epidural anesthesiafollowing epidural anesthesia

The incidence is highest among The incidence is highest among outpatients (early ambulation?) after outpatients (early ambulation?) after surgery in the lithotomy position and surgery in the lithotomy position and lowest in inpatients done in positions lowest in inpatients done in positions other than lithotomyother than lithotomy


The pathogenesis of TNS is assumed to be The pathogenesis of TNS is assumed to be due to concentration-dependent due to concentration-dependent neurotoxicity of the LA’sneurotoxicity of the LA’s

Epidural Abscess must be considered if Epidural Abscess must be considered if symptoms progress from just pain to other symptoms progress from just pain to other neurologic deficitsneurologic deficits

NSAIDS or Acetaminophen can be used for NSAIDS or Acetaminophen can be used for the duration of symptoms, but if they fail the duration of symptoms, but if they fail to resolve in a few days, a Neurology to resolve in a few days, a Neurology consultation is warranted with a careful consultation is warranted with a careful physical exam performedphysical exam performed

Cauda Equina SyndromeCauda Equina Syndrome

Cauda Equina Syndrome (CES) is Cauda Equina Syndrome (CES) is associated with the use of associated with the use of CONTINUOUS Spinal catheters and CONTINUOUS Spinal catheters and Lidocaine 5%Lidocaine 5%

CES is characterized by bowel and CES is characterized by bowel and bladder dysfunction together with bladder dysfunction together with evidence of multiple nerve root injury evidence of multiple nerve root injury of the lower extremitiesof the lower extremities

It can manifest as both motor and It can manifest as both motor and sensory deficits sensory deficits


The patient may have significant pain The patient may have significant pain in the distribution of individual nerve in the distribution of individual nerve roots or a generalized pain of both roots or a generalized pain of both lower extremitieslower extremities

The cause seems to be The cause seems to be maldistribution of hyperbaric solutions maldistribution of hyperbaric solutions of lidocaine with a higher of lidocaine with a higher concentration of Lido 5% coming in concentration of Lido 5% coming in contact with particular nerves and contact with particular nerves and causing a toxic reaction between the causing a toxic reaction between the LA and the nerve root(s) LA and the nerve root(s)


The incidence is highest in cases that The incidence is highest in cases that utilize Spinal Catheters and Lido 5%, utilize Spinal Catheters and Lido 5%, next is Single shot spinals with next is Single shot spinals with multiple LA’s, then comes Epiduralsmultiple LA’s, then comes Epidurals

It is a very rare complication and It is a very rare complication and seems to occur in this order of LA’s: seems to occur in this order of LA’s: Lidocaine = Tetracaine > Bupivicaine Lidocaine = Tetracaine > Bupivicaine > Ropivicaine> Ropivicaine

ConclusionConclusion

You can see that the performance of You can see that the performance of neuraxial blockades have quite a few neuraxial blockades have quite a few complications that can be associated complications that can be associated with their usewith their use

You must be familiar with them all, You must be familiar with them all, regardless of how rare a particular regardless of how rare a particular side effect or complication may occurside effect or complication may occur

ConclusionConclusion

Again, even during a seemingly Again, even during a seemingly uneventful block, keep thinking uneventful block, keep thinking “What if…?” because one day your “What if…?” because one day your “What if…?” will turn into an actual “What if…?” will turn into an actual complication and the more you know complication and the more you know and plan, the better prepared you and plan, the better prepared you will be to deal with whatever may will be to deal with whatever may come upcome up

Remember to always stay one step Remember to always stay one step ahead and you can keep yourself ahead and you can keep yourself AND your patient out of troubleAND your patient out of trouble

Regional Anesthetic Complications Vgc07

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