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Regional Anesthetic Complications. Vincent Conte, MD Associate Clinical Professor Nurse Anesthesia Program FIU College of Nursing and Health Sciences. RA Complications. Presentation divided into two sections: Contraindications Complications (both Spinal & Epidural). Assessment.

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regional anesthetic complications

Regional Anesthetic Complications

Vincent Conte, MD

Associate Clinical Professor

Nurse Anesthesia Program

FIU College of Nursing and Health Sciences

ra complications
RA Complications
  • Presentation divided into two sections:
  • Contraindications
  • Complications (both Spinal & Epidural)
  • If a neuraxial anesthetic is being considered, the risks and benefits need to be discussed with the patient
  • An INFORMED CONSENT needs to be obtained prior to performing any neuraxial anesthetic
  • A careful H & P and PE need to be done to make sure there are no CONTRAINDICATIONS to performing a neuraxial anesthetic
  • Patients should understand prior to their block, that once the block is performed they will have little or no motor function until the effects of the block wears off
  • Patients should also be warned that once the block takes effect, they may feel like their limbs are in various positions (straight up, bent or folded, etc.) but are really still and flat against the bed or any rests or padding that you provide
physical exam
Physical Exam
  • Prior to ANY Spinal or Epidural anesthetic, a CAREFUL examination of the back should be made. Things to look for are:

Surgical Scars


Skin lesions

Palpable Spinous Processes

physical exam6
Physical Exam
  • Although no preoperative screening tests are required for healthy patients undergoing neuraxial blockade, coagulation studies and platelet count should be checked when clinical history suggests the possibility of a bleeding diasthesis
  • There are certain ABSOLUTE contraindications to Regional Anesthesia:
  • Infection at the site:

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


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


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

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


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

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


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

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

relative contraindications
Relative Contraindications
  • Relative Contraindications are:

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

relative contraindications14
Relative Contraindications

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

relative contraindications15
Relative Contraindications

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

relative contraindications16
Relative Contraindications

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

  • This is a major source of liability connected with the use neuraxial blockade
relative contraindications17
Relative Contraindications

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

relative contraindications18
Relative Contraindications

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

relative contraindications19
Relative Contraindications

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

relative contraindications20
Relative Contraindications

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

controversial contraindications
Controversial Contraindications

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

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

controversial contraindications22
Controversial Contraindications

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

controversial contraindications23
Controversial Contraindications

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

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

controversial contraindications24
Controversial Contraindications

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

controversial contraindications25
Controversial Contraindications

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

neuraxial blockade in the setting of anticoagulants antiplatelet agents
Neuraxial Blockade in the Setting of Anticoagulants & Antiplatelet Agents

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

antiplatelet drugs
Antiplatelet Drugs

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

antiplatelet drugs28
Antiplatelet Drugs

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

standard heparin
Standard Heparin

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

antiplatelet drugs30
Antiplatelet Drugs

3) Standard Heparin (cont’d):

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

low molecular weight heparin
Low-Molecular Weight Heparin

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

fibrinolytic thrombolytic therapy
Fibrinolytic/Thrombolytic Therapy

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




  • The complications of Epidural, Spinal and Caudal anesthetics range from bothersome to the crippling and life-threatening
  • Broadly, the complications can be thought of as resulting from exaggerated physiologic side effects, placement of the needle, and drug toxicity
  • A very large study of regional anesthetics from France provides an indication of the relatively low incidence of serious complications
  • In contrast, the ASA Closed Claim project helps identify the most common causes of LIABILITY claims involving Anesthetic complications in the OR setting
  • In a 20 year period (1980-1999) regional anesthesia accounted for 18% of ALL liability claims. The claims were broken down by:
  • Temporary or Non-disabling (11.5%)
  • Serious injuries (death – 2.3%; permanent nerve injury – 1.8%; permanent brain damage – 1.4% and other permanent injuries – 0.72%)
  • Lumbar EPIDURAL anesthesia accounted for 42% of all cases
  • Spinal anesthesia accounted for 34% of all cases
  • Caudal anesthesia was utilized in only 2% of all cases
  • ALL types had their complications occur mostly in Obstetric patients (this reflects the higher percentage of use of regional anesthesia in these patients; 68%)
  • In the French study, the percentages were MUCH lower
  • Out of 40,640 patients who had SPINALS, 0.00006% suffered cardiac arrests, 0.0001% died, 0.00004% had permanent nerve injury
  • Out of 30,413 patients who had EPIDURALS, 0.00009% had cardiac arrests, 0% died and 0.0001% suffered permanent nerve injury

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

exaggerated physiologic side effects
Exaggerated Physiologic Side Effects
  • These are:
  • Hypotension
  • Bradycardia
  • High Neural Block
  • Total Spinal
  • Cardiac Arrest during Spinal
  • Urinary Retention
  • Nausea
  • Hypoventilation
  • Hypotension is estimated to occur in about 1/3 of patients receiving spinal anesthesia and in about 1/5 of all patients receiving epidurals
  • The hypotension results from sympathetic nervous system blockade that:

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

b) Decreases Systemic Vascular Resistance (SVR)

  • Modest decreases in blood pressure are most likely from a drop in SVR
  • Large drops in blood pressure are from BOTH a drop in SVR & Cardiac Output
  • The degree of hypotension often parallels the level of spinal anesthesia and the intravascular fluid volume of the patient
  • With hypovolemia, the extent of hypotension can be markedly increased
hypotension treatment
Hypotension - Treatment
  • Is treated physiologically by restoration of venous return so as to increase cardiac output
  • Head down position (restore volume)
  • Volume administration (increase preload)
  • Pharmacologic correction of decreased SVR (Neo) and drop in cardiac output (Ephedrine)
hypotension treatment43
  • BE CAREFUL not to OVER-hydrate patients who may be at risk for heart failure from fluid overload
  • These are elderly patients, patients with ischemic heart disease or a history of any type of valvular heart disease, patients with a history of Congestive Heart Failure
  • In these patients, a Neo drip may be needed instead of very aggressive hydration
  • Occurs in 10-15% of patients receiving spinal anesthesia
  • Risk increases with increasing level of anesthesia
  • Caused by block of cardioaccelerator fibers originating from T1-T4
  • Usually promptly responds to treatment with Atropine 0.2-0.4mg
  • There are reported cases of sudden Asystole in the absence of any obvious preventable events
  • For Asystole, prompt intervention with Epinephrine is usually necessary to correct the problem
high neural blockade
High Neural Blockade
  • High levels of neural blockade can occur readily with either spinal or epidural anesthesia
  • Causes are usually:
  • Administration of an excessive dose
  • Failure to reduce standard dose in selected patients (elderly, pregnant, obese or very short patients)
  • Unusual sensitivity or spread of local anesthetic
high neural blockade46
High Neural Blockade
  • Spinal anesthesia ascending into the cervical levels causes SEVERE hypotension, bradycardia (blockade of cardiac accelerator fibers) and respiratory insufficiency
  • Unconsciousness, apnea and hypotension resulting from high levels of spinal anesthesia are referred to as a “High Spinal” or a “Total Spinal”
high neural blockade47
High Neural Blockade
  • A High Spinal or Total Spinal can also occur following an attempted epidural/caudal if there is inadvertent intrathecal injection
  • Sustained severe hypotension with a LOW block can also lead to apnea via severe medullary hypoperfusion
high neural blockade48
High Neural Blockade
  • Symptoms of a High neural block include dyspnea and numbness or weakness in the upper extremities
  • Nausea w or w/o vomiting usually occurs and precedes the development of hypotension
  • This may continue to develop into severe hypotension, bradycardia and respiratory insufficiency or total apnea
high neural blockade49
High Neural Blockade
  • Treatment of a high block or total spinal include supplemental oxygen and maintaining an adequate airway (from a simple chin lift to placement of an ETT)
  • Treatment also involves support of circulation with volume, head down position and vasopressors (see treatment of hypotension)
high neural blockade50
High Neural Blockade
  • If conventional methods do not work with the hypotension, then an Epi drip and boluses may be needed
  • Bradycardia should be treated promptly with Atropine and/or Epi
  • If respiratory and hemodynamic control can be maintained, surgery may proceed
  • If vital signs remain unstable despite aggressive treatment, then surgery should be cancelled and the patient sent to an ICU bed as soon as they are stabilized
cardiac arrest
Cardiac Arrest
  • Large Prospective studies report a relatively high incidence of cardiac arrest in patients having a spinal anesthetic (1:1500)
  • Many of the arrests were preceded by episodes of sudden bradycardia and occurred in young healthy patients with a low resting heart rate preoperatively
cardiac arrest52
Cardiac Arrest
  • A recent study recognized strong vagal responses and decreased preload as key factors in development of CA
  • To prevent this occurrence, any patient with a low resting heart rate preoperatively should be treated with prophylactic volume expansion and PROMPT treatment of bradycardia with Atropine, pressors or Epi as needed
urinary retention
Urinary Retention
  • Spinal Anesthesia blocks the S2-S4 root fibers decreasing urinary bladder tone and inhibits the voiding reflex
  • This may require catheterization to relieve distension
  • The bladder paralysis is time dependent and as the LA wears off, the normal bladder tone and voiding reflex should return
  • There are rare instances in which the LA has worn off, yet the bladder still gets distended and requires catheterization
urinary retention54
Urinary Retention
  • These patients may have to be admitted overnight and usually an indwelling foley is placed until the bladder regains tone
  • No Out-patient receiving neuraxial block should be discharged until the patient can void voluntarily
  • Also, if bladder dysfunction persists even after the block has worn off, this may be a manifestation of serious neural injury secondary to the performance of the block
  • At that point a Neurology Consultation may be in order
  • Nausea occurring shortly after initiation of a spinal anesthetic must alert the Anesthetist to the possible presence of hypotension sufficient to cause cerebral ischemia
  • Treatment of the hypotension should also treat the nausea (see Hypotension)
  • Another cause of nausea during a spinal anesthetic is a predominance of parasympathetic stimulation of the GI tract (Sympathetics are blocked)
  • Treatment with Atropine (0.2-0.4mg) may be effective therapy (blocking muscarinic effects)
  • Zofran or Anzimet may also be used instead of Atropine
  • Exaggerated hypoventilation may accompany IV administration of drugs intended to produce sedation during the planned procedure
  • It is believed to be from an enhanced effect of the drugs due to the sympathetic nervous system blockade
  • Vigilance and attention to your patient and monitors will help you discover this rare complication if it ever occurs
complications associated with needle or catheter insertion
Complications Associated with Needle or Catheter Insertion
  • The following can be caused by needle or catheter insertion:
  • Inadequate Anesthesia or Analgesia
  • Intravascular Injection
  • Subdural Injection
  • Backache
  • Postdural Puncture Headache
  • Neurological Injury/Transient Radicular Irritation
  • Spinal or Epidural Hematomas
  • Meningitis or Arachnoiditis
  • Epidural Abscess
  • Sheering of an Epidural Catheter
inadequate spinal anesthesia
Inadequate Spinal Anesthesia
  • All neuraxial blocks are “blind” techniques and as such will always have a failure rate associated with them
  • The failure rate is commonly inversely proportional to the clinician’s experience
  • Even with the endpoint of spinal anesthesia being free flow of CSF, failure can still occur secondary to needle movement during injection, incomplete entry of needle opening into the SAS, (aspirate before AND after injection) or loss of potency of LA due to age
inadequate epidural anesthesia
Inadequate Epidural Anesthesia
  • Unlike Spinal anesthesia with its defined endpoint (clear flow of CSF), Epidural anesthesia is dependent on detection of a subjective LOR and variable anatomy of the epidural space and less predictable spread of LA
inadequate epidural anesthesia61
Inadequate Epidural Anesthesia
  • Misplaced injections can occur in a number of situations:
  • False LOR is obtained in soft, pliable spinal ligaments found in young patients
  • Para-spinous muscle injections with a misplaced off-center injection can simulate LOR
  • Your injection can go subdural or intravascular instead of into the epidural space
inadequate epidural anesthesia62
Inadequate Epidural Anesthesia

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

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

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

intravascular injection
Intravascular Injection
  • Inadvertent intravascular injection of LA can produce very high serum levels of LA’s very rapidly
  • High levels in the CNS can cause seizures and unconsciousness
  • High levels in the Cardiovascular system can cause hypotension, arrhythmias and eventual cardiovascular collapse
intravascular injection64
Intravascular Injection
  • Because the dosage of anesthetic is so much smaller with a spinal, these complications rarely occur with a spinal but are primarily seen with epidurals and caudals
  • LA can be injected directly into a vein by the needle or later through the catheter that has migrated into a blood vessel
intravascular injection65
Intravascular Injection
  • The incidence of intravascular injection can be minimized by carefully ASPIRATING the needle or catheter BEFORE EVERY injection!!
  • Also, the incidence can be reduced by the use of a test dose with Epi to see if you get a sudden increase in heart rate
intravascular injection66
Intravascular Injection
  • Severe side effects can also be prevented by ALWAYS injecting meds in increments of 3-5cc and waiting to see if any side effects occur (ringing in ears, metallic taste in mouth, circumoral numbness, lightheadedness, SUDDEN weakness or numbness in legs)
subdural injection
Subdural Injection
  • The SUBDURAL space (different from the Subarachnoid space) is a potential space between the DURA and the ARACHNOID and extends intracranially so any LA injected into the subdural space can produce much more serious complications than a high epidural can
  • A subdural injection can mimic a Total Spinal in its symptoms and physiologic changes
subdural injection68
Subdural Injection
  • As with inadvertent IV injection, inadvertent subdural injection of LA during an EPIDURAL can become a disaster if not recognized in a timely fashion
  • The clinical presentation is similar to that of a Total Spinal and the management is similar as well
  • The exception is that the onset may be delayed for 15-30 minutes due to lower concentrations of agents used
subdural injection69
Subdural Injection
  • Again, the incidence of this occurring can be reduced by incremental dosing and use of a test dose with epi
  • The symptoms will resemble those of a subarachnoid injection of your epidural anesthesia with sudden onset of numbness and weakness of the lower extremities
  • As a needle passes through the skin, subq tissues, muscle and ligaments it causes varying degrees of tissue trauma
  • A localized inflammatory response with or w/o muscle spasm may be responsible for the presentation of a postop backache
  • The more difficult the procedure was will also increase the chances of the patient experiencing a postop backache
  • It should be noted that up to 25-30% of patients receiving GA ALONE also complain of a backache postop
  • If it does occur, the backache or soreness is usually mild and self-limited
  • It can last for up to several weeks in some cases depending again on how much trauma was done during the procedure
  • Treatment is usually initially with Acetaminophen and warm then cold compresses
  • If stronger treatment is needed, then NSAID’s can be added to the regimen
  • If PO intake is not possible at that point, Cox2 Inhibitors IV (Toradol) can be given for 2-3 days then converted to PO when possible
  • In RARE cases Narcotics can be prescribed if pain is severe or unresponsive to other conventional treatment methods
  • If the backache persists despite treatment or gets worse, then this may be a sign of a more serious complication occurring and a Neurology consultation may be warranted (abscess, hematoma, etc.)
post dural puncture headache
Post-Dural Puncture Headache
  • Characterized as frontal or occipital
  • Hallmark Feature: Worsens with postural changes such as sitting or standing
  • Supine, pain usually resolves when lying FLAT
  • Occasionally accompanied by Tinnitus and decreased hearing
post dural puncture headache75
Post-Dural Puncture Headache
  • A headache w/o postural changes IS NOT a Post-dural puncture headache
  • Caused by decreased CSF pressures and resulting tension on meningeal vessels and nerves as a result of leakage of CSF through the needle’s hole in the dura
  • Incidence decreases with increasing age and drops off rapidly over 55 years of age
post dural puncture headache76
Post-Dural Puncture Headache
  • Incidence can be decreased by:
  • Using a rounded point needle (Sprotte or Whitacre)
  • The point of the needle used to puncture the dura is oriented PARALLEL rather than perpendicular to the meningeal fibers (running up and down)
  • Using a small gauge needle (25g)
treatment of pdph
Treatment of PDPH
  • Initially with bed rest, analgesics and oral/IV hydration
  • If headache persists after 24-48 hours, it is recommended to do a “Blood Patch” as the next line of therapy
  • Blood patch is done by injecting 10-20cc of the patient’s blood epidurally at or near the same interspace that the original spinal anesthetic or dural puncture was performed
treatment of pdph79
Treatment of PDPH
  • Prompt relief of the headache occurs in 85% of patients that receive a blood patch
  • Due to the blood “Sealing” the hole and slowing or stopping the leak of CSF
  • Of those patients who do not respond to the initial blood patch, 90% will respond to a second blood patch
  • Most common side effects of blood patch are backache and radicular pain; usually resolves within 24 hours
treatment of pdph80
Treatment of PDPH
  • An alternate treatment is administration of IV Caffeine sodium benzoate (500mg)
  • It has been shown to be effective in about 70% of patients with PDPH
  • A controversial treatment is to inject NS or blood through an epidural catheter if it had occurred as a result of an epidural, as a prophylactic measure before taking out the catheter
  • No study has been done that shows if NS or blood via the catheter works or not
neurological injury
Neurological Injury
  • Serious neurologic injury is a rare but widely feared complication of epidural and spinal anesthesia
  • Multiple large number studies have shown that the incidence of neurologic injury occurs between 0.03 and 0.1% of all central neuraxial block patients
  • Of note is that in most of these series, the block was not proven to be causative
neurologic injury
Neurologic Injury
  • Persistent paresthesias and limited motor weakness are the most common injuries, although paraplegia and diffuse injury to cauda equina roots (cauda equina syndrome) do occur, but rarely
  • There does seem to be a slightly higher rate of injury associated with Epidurals vs. Spinals and this is thought to be due to the larger size of the needle used in Epidurals
neurologic injury83
Neurologic Injury
  • Injury may result from:

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

b) Spinal cord ischemia

neurological injury84
Neurological Injury
  • Spinal cord injury can be avoided by performing your block below L1 in adults and L3 in Pediatric patients
  • Also, any persistent parasthesia during injection or catheter passage should be dealt with by immediately stopping what you are doing and withdrawing either the needle of cath a few cm and then try again
neurological injury85
Neurological Injury
  • Direct injection into the spinal cord can cause paraplegia
  • Damage to the Conus Medullaris may cause isolated sacral dysfunction with lower extremity muscle weakness and loss of bowel or bladder function
  • Needles can cause direct physical trauma to spinal nerve roots as well
neurological injury86
Neurological Injury
  • Although most neurologic complications resolve spontaneously, some become permanent
  • Most permanent deficits have been associated with parasthesias from either needle or catheter that were not dealt with appropriately (withdrawing needle or catheter as soon as it is established that the parasthesia is persisting)
neurological injury87
Neurological Injury
  • Some studies have suggested that multiple attempts of a difficult block raise the chance of needle trauma significantly (Don’t be a hero!! If you can’t get the block after 2-3 tries, call for help and another pair of hands!!)
neurological injury spinal ischemia
Neurological Injury: Spinal Ischemia
  • Spinal cord Ischemia usually occurs as a result of Global systemic hypotension and with the additional pressure being placed on the spinal cord by the epidural anesthetic, a higher level of pressure is needed to perfuse the spinal cord as a result of the external pressure
  • Treatment is prompt treatment of hypotension
neurological injury obstetrics
Neurological Injury: Obstetrics
  • A few things to keep in mind when dealing with Obstetric patients:

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

neurological injury obstetrics90
Neurological Injury: Obstetrics
  • Postpartum deficits usually involve Lateral Femoral Cutaneous neuropathy (weakness of legs and pain in both inner thighs), foot drop, and possibly paraplegia
  • Again, these injuries occur even without a block, so if any of these types of injuries are reported after a long labor with an epidural, they are most commonly from nerve trauma during delivery
neurological injury obstetrics91
Neurological Injury: Obstetrics
  • Get a Neurology consultation ASAP just in case, but the Neurologist will usually clear your block of any blame once the symptoms are disclosed and the patient is examined
  • In most cases these injuries are self-limiting and will resolve within a week or two, so reassure your patient that what they are feeling is temporary and is secondary from their labor and delivery and NOT your block but don’t forget, DOCUMENT, DOCUMENT, DOCUMENT!!!
neurological injury obstetrics92
Neurological Injury: Obstetrics
  • If, however, their symptoms persist longer than a few weeks, the OB doc will probably send the patient to a neurologist and if there is the slightest chance that the symptoms are from your block, believe me the patient will get in touch with you so fast it will make your head spin
  • When the smell of money is in the air, people tend to work very quickly and efficiently
transient radicular irritation
Transient Radicular Irritation
  • Transient Radicular Irritation of the Lumbosacral nerves manifests as moderate to severe pain in the lower back, buttocks, and posterior thighs
  • Usually appears within 24 hours AFTER complete recovery from a Spinal anesthetic
  • The delayed onset of pain reflects the development of inflammation and irritation
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Transient Radicular Irritation
  • Full recovery usually occurs within 7 days
  • Bupivicaine and Tetracaine are associated with a LOWER incidence of occurrence
  • Treatment revolves around the use of NSAIDS to decrease inflammation
  • In rare cases, steroids may need to be administered PO to decrease the inflammatory response
  • Persistent pain may be due to infection or abscess formation and then aggressive treatment is necessary
spinal or epidural hematoma
Spinal or Epidural Hematoma
  • Needle or catheter trauma to epidural veins often causes minor bleeding in the spinal canal that is usually benign and self-limiting
  • Unfortunately, sometimes the bleeding can lead to the formation of a significant hematoma (spinal or epidural)
spinal epidural hematomas
Spinal/Epidural Hematomas
  • The incidence of such hematomas has been estimated to be about 1:150,000 for epidurals and 1:220,000 for spinal anesthetics
  • The vast majority of reported cases have occurred in patients with abnormal coag numbers either secondary to disease or pharmacologic therapies
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Spinal/Epidural Hematomas
  • It should be noted that some hematomas have been associated with REMOVAL of an epidural catheter as well as insertion
  • The hematomas result in a mass effect on the spinal cord with anywhere from mild to severe symptoms
  • Unless the condition is diagnosed rapidly and appropriate treatment is instituted as soon as possible, permanent neurologic injury can occur
spinal epidural hematoma
Spinal/Epidural Hematoma
  • Symptoms typically appear suddenly and include sharp back pain and leg pain with a progression to numbness, motor weakness and sphincter dysfunction
  • MRI or CT must be obtained as soon as the possibility of a hematoma is considered as well as a Neurology consultation ASAP
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Spinal/Epidural Hematoma
  • In many cases good neurological recovery has occurred in patients who have undergone surgical decompression within 8-12 hours (and needless to say that their anesthesia bill is wiped clean and their #$@% is kissed thoroughly)
  • To prevent its occurrence, Neuraxial anesthesia should be avoided in any patient with coagulopathies, significant thrombocytopenia (<80-100,000), platelet dysfunction or those who have received fibrinolytic/thrombolytic therapy within 5 days of possibly receiving a block
meningitis arachnoiditis
Meningitis & Arachnoiditis
  • Infection of the Subarachnoid or Epidural space can follow neuraxial blocks as the result of contamination of the equipment or injected solutions or as a result of organisms tracked in from the skin
  • Indwelling catheters can become infected and track deep along the catheter’s path
  • Although possible, thankfully these are rare complications
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Meningitis & Arachnoiditis
  • Another rarely reported complication is Arachnoiditis
  • It can be either infectious or non-infectious
  • Clinically, signs are pain and other neurological symptoms and an MRI/CT scan will show CLUMPING of nerve roots
  • It is often seen following epidural steroid injections but most commonly seen after spinal surgery or trauma
epidural abscess
Epidural Abscess
  • Epidural abscess (EA) is a rare but devastating complication of neuraxial anesthesia
  • The incidence varies widely from 1:6500 to 1:500,000 epidurals depending on which study you look at
  • EA can even occur in patients who never received a neuraxial block (systemic spread)
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Epidural Abscess
  • Most anesthesia cases are associated with the use of an Epidural catheter
  • A hallmark of EA is the long delay in appearance of symptoms; one study showed a mean period of 5 days from insertion to symptoms
  • Sometimes presentation can be delayed for weeks
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Epidural Abscess
  • Initially symptoms usually appear as back or vertebral pain which worsens during percussion over the spine
  • Next, nerve root or radicular pain usually develops
  • This is usually followed by motor and sensory deficits and sphincter dysfunction
  • The final stage is usually paraplegia or paralysis
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Epidural Abscess
  • Prognosis is associated with the degree of neurological dysfunction at the time of diagnosis
  • Back pain and fever should alert the clinician to the possibility of an EA
  • Once EA is suspected, if a catheter is in place it needs to be removed ASAP and MRI/CT scan needs to be obtained right away
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Epidural Abscess
  • The catheter tip should be cultured and the insertion hole should be expressed to see if any pus is present. This should be cultured as well
  • IV antibiotic therapy should be instituted after cultures are obtained and an Infectious Disease consult ordered at once
  • Neurosurgical consultation should also be obtained ASAP
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Epidural Abscess
  • Treatment usually involves surgical drainage and decompression especially if neurologic deficits exist
  • There are very few reports of patients recovering by the use of antibiotics alone
  • Measures to prevent it include minimal catheter manipulation and removal of any catheter after a maximum of 96 hours in place
sheering of an epidural catheter
Sheering of an Epidural Catheter
  • This is always a risk with any catheter through needle technique
  • It can happen especially if the epidural catheter is pulled BACK through the needle after its insertion
  • If for some reason a catheter gets stuck during insertion then the catheter and needle must be withdrawn together as a unit and a new catheter placed from the start
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Sheering of an Epidural Catheter
  • If a catheter breaks of or sheers off deep within the epidural space, experts suggest leaving it alone and carefully observing the patient
  • If the breakage occurs in the subQ tissue, particularly if part of the catheter is visible, it should be removed right away either manually or surgically
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Sheering of an Epidural Catheter
  • In studies following patients with sheered catheters in place, long term complications are rare and most can continue on without any complications or problems
  • However, in a small number of patients, the catheter causes an immune reaction that can mimic an Epidural Abscess and then has to be removed surgically
sheered catheter
Sheered Catheter
  • Basically, if it happens, get a baseline Neurologic Consultation which will probably include an MRI/CT Scan and INFORM the patient of the complication. A neurosurgical consult isn’t a bad idea either. DOCUMENT, DOCUMENT, DOCUMENT
  • Tell the patient that the vast majority of the people that this happens to go on and never have a problem for the rest of their lives BUT ALSO tell them that a very small percentage DO develop symptoms that may need further medical attention
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Sheered Catheter
  • Tell them the symptoms that they may feel can range from back pain to having weakness or numbness in their legs and that if any symptoms develop that persist for longer than 2-3 days, to call immediately and NOT to delay calling
  • Give them a phone number to call that WILL be available even if you are not!!
missing tip
Missing Tip
  • Just as an aside that is semi-related to a Sheered Cath, whenever you are called to REMOVE an epidural catheter, ALWAYS look at the tip when it is removed and DOCUMENT that the tip was seen
  • The tip is a THICK line that makes the tip of the catheter black, so always make sure you see it and if you don’t, then DOCUMENT and contact the person who put it in and SAVE, SAVE, SAVE the cath in a bag or a glove to show the person who put it in because they probably won’t believe you when you tell them
complications associated with drug toxicity
Complications Associated with Drug Toxicity
  • There are three different clinical situations that can arise from direct toxicity of the LA’s:
  • Systemic Toxicity
  • Transient Neurological Symptoms
  • Lidocaine Neurotoxicity (Cauda Equina Syndrome)
systemic toxicity
Systemic Toxicity
  • Systemic toxicity occurs when there is absorption of excessive amounts of LA’s which produces high, toxic serum levels
  • Excessive absorption from epidural or caudal blocks is very rare, especially if the dose used is within the recommended guidelines of dosage per kilogram
  • It is much more commonly caused by direct intravascular injection (which was previously discussed)
transient neurological symptoms
Transient Neurological Symptoms
  • Transient Neurological Symptoms was first described in 1993
  • It is also referred to as Transient Radicular Irritation and is characterized by back pain radiating to the legs W/O sensory or motor deficit
  • The symptoms characteristically occur AFTER the block has worn off and resolves spontaneously within a few days
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Transient Neurological Symptoms
  • It is most commonly associated with hyperbaric Lidocaine (11.9%), Tetracaine ( 1.6%), Bupivicaine ( 1.3%)
  • There are also case reports of TNS following epidural anesthesia
  • The incidence is highest among outpatients (early ambulation?) after surgery in the lithotomy position and lowest in inpatients done in positions other than lithotomy
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Transient Neurological Symptoms
  • The pathogenesis of TNS is assumed to be due to concentration-dependent neurotoxicity of the LA’s
  • Epidural Abscess must be considered if symptoms progress from just pain to other neurologic deficits
  • NSAIDS or Acetaminophen can be used for the duration of symptoms, but if they fail to resolve in a few days, a Neurology consultation is warranted with a careful physical exam performed
cauda equina syndrome
Cauda Equina Syndrome
  • Cauda Equina Syndrome (CES) is associated with the use of CONTINUOUS Spinal catheters and Lidocaine 5%
  • CES is characterized by bowel and bladder dysfunction together with evidence of multiple nerve root injury of the lower extremities
  • It can manifest as both motor and sensory deficits
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Cauda Equina Syndrome
  • The patient may have significant pain in the distribution of individual nerve roots or a generalized pain of both lower extremities
  • The cause seems to be maldistribution of hyperbaric solutions of lidocaine with a higher concentration of Lido 5% coming in contact with particular nerves and causing a toxic reaction between the LA and the nerve root(s)
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Cauda Equina Syndrome
  • The incidence is highest in cases that utilize Spinal Catheters and Lido 5%, next is Single shot spinals with multiple LA’s, then comes Epidurals
  • It is a very rare complication and seems to occur in this order of LA’s: Lidocaine = Tetracaine > Bupivicaine > Ropivicaine
  • You can see that the performance of neuraxial blockades have quite a few complications that can be associated with their use
  • You must be familiar with them all, regardless of how rare a particular side effect or complication may occur
  • Again, even during a seemingly uneventful block, keep thinking “What if…?” because one day your “What if…?” will turn into an actual complication and the more you know and plan, the better prepared you will be to deal with whatever may come up
  • Remember to always stay one step ahead and you can keep yourself AND your patient out of trouble