Serious complications associated with spinal and epidural anaesthesia in Finland from 2000 to 2009

Epidemiologic investigation on neurological complications following neuraxial anesthesia in 2.7 million cases in Southwest China

Neuraxial anesthesia provides effective anesthesia and analgesia for surgery, but may cause neurological complications. The rate of neurological complications in China remains unclear. This study conducted a retrospective epidemiological investigation of neurological complications following neuraxial anesthesia in Guangxi, southwest China. This survey used the "Golden Data" platform to distribute questionnaires to anesthesiology departments across hospitals of varying levels in Guangxi, gathering data on neuraxial anesthesia methods and associated neurological complications from 2013 to 2022. Detailed patient information was recorded, with missing data supplemented by phone. The Adverse Event Reporting System was also utilized to verify and supplement cases, supported by peer review. The study analyzed the incidence and clinical characteristics of neurological complications after neuraxial anesthesia. A comprehensive survey was conducted across 243 hospitals, encompassing 2,723,615 cases of neuraxial anesthesia. The survey identified 1208 cases of neurological complications, with an incidence of 0.44‰, primarily occurring in patients undergoing obstetrics, gynecology, orthopedics, urology, and general surgery. The complications included transient nerve syndrome (999 cases), spinal injury (188 cases), cauda equina syndrome (13 cases), spinal hematoma (5 cases), anterior spinal artery syndrome (2 cases), and conus medullaris injury (1 case). The incidence of neurological complications associated with combined spinal-epidural anesthesia (0.53‰) was significantly higher than that of epidural anesthesia (0.21‰) and spinal anesthesia (0.35‰) (P < 0.001). Among the patients, 97.3% achieved full recovery, while 2.7% (30 cases) suffered permanent neurological damage. Although neurological complications are relatively rare, comprehensive preoperative assessment, adherence to standardized protocols, and vigilance regarding potential complications are essential.

ASRA Pain Medicine consensus practice infection control guidelines for regional anesthesia and pain medicine

BACKGROUND

To provide recommendations on risk mitigation, diagnosis and treatment of infectious complications associated with the practice of regional anesthesia, acute and chronic pain management.

METHODS

Following board approval, in 2020 the American Society of Regional Anesthesia and Pain Medicine (ASRA Pain Medicine) commissioned evidence-based guidelines for best practices for infection control. More than 80 research questions were developed and literature searches undertaken by assigned working groups comprising four to five members. Modified US Preventive Services Task Force criteria were used to determine levels of evidence and certainty. Using a modified Delphi method, >50% agreement was needed to accept a recommendation for author review, and >75% agreement for a recommendation to be accepted. The ASRA Pain Medicine Board of Directors reviewed and approved the final guidelines.

RESULTS

After documenting the incidence and infectious complications associated with regional anesthesia and interventional pain procedures including implanted devices, we made recommendations regarding the role of the anesthesiologist and pain physician in infection control, preoperative patient risk factors and management, sterile technique, equipment use and maintenance, healthcare setting (office, hospital, operating room), surgical technique, postoperative risk reduction, and infection symptoms, diagnosis, and treatment. Consensus recommendations were based on risks associated with different settings and procedures, and keeping in mind each patient's unique characteristics.

CONCLUSIONS

The recommendations are intended to be multidisciplinary guidelines for clinical care and clinical decision-making in the regional anesthesia and chronic interventional pain practice. The issues addressed are constantly evolving, therefore, consistent updating will be required.

Hips Do Not Lie: Atypical Pain From Peripartum Pubic Symphysis Diastasis

Pubic symphysis diastasis (PSD) is the widening of the pubic symphysis which can occur during the peripartum period. PSD commonly presents as pelvic pain with associated neuropathies rarely reported. In this report we describe the unique presentation of PSD with associated motor and sensory deficits in a 19-year-old postpartum patient. Two days following vaginal delivery, the patient complained of diffuse body pain, generalized weakness, and lower extremity paresthesia without any other neurological deficits. PSD was diagnosed by radiograph of the pelvis and her symptoms swiftly improved following conservative management of the diastasis. Further, we discuss the potential etiology of this patient's presentation as well as differential diagnosis with similar presentations.

Utility of spinal anesthesia in plastic surgery and other surgical subspecialties: A literature review

INTRODUCTION

Spinal anesthesia (SA) is commonly used within the specialties of orthopedic surgery, obstetrics and gynecology, spine surgery, and general surgery, and offers several benefits over general anesthesia (GA). However, SA is used much less frequently in plastic surgery. This review analyzed currently existing data on SA use across various surgical specialties and compared the benefits and complications of SA to those of GA, to assess its utility and potential for more widespread use in plastic surgery.

METHODS

A comprehensive literature review was conducted using the PubMed and Cochrane Library databases to evaluate the utility of SA in plastic surgery. Indications, contraindications, and data on the use of SA across various surgical specialties were reviewed. Benefits, complications, and cost-effectiveness were also assessed. Finally, the utility of SA in plastic surgery was evaluated based on the available literature.

RESULTS

SA has been shown to yield several benefits and fewer risks than GA, including a higher possibility of early discharge, decreased costs, better pain and postoperative nausea and vomiting control, and decreased risk of deep venous thrombosis and pulmonary embolism.

CONCLUSION

Although commonly used for procedures across various surgical specialties such as obstetrics and gynecology, urology, and orthopedic surgery, SA is less frequently used within plastic surgery. Plastic surgery procedures that would benefit from the use of SA include those below the umbilicus such as liposuction, lower extremity procedures, and perineal procedures, and owing to its benefits, we recommend that SA be used more often within plastic surgery under appropriate clinical circumstances.

Total spinal anaesthesia following obstetric neuraxial blockade: a narrative review

BACKGROUND

Total spinal anaesthesia (TSA) is an emergency caused by high neuraxial blockade. It is a recognised complication of all neuraxial techniques in obstetric anaesthesia. Its incidence and outcomes have not been evaluated. There is compelling evidence that TSA continues to be a problem in contemporary practice, having the capacity to cause significant morbidity and mortality if not recognised early and promptly treated. This review based on a literature search aims to clarify the epidemiology of TSA, summarise its pathophysiology, and identify risk factors and effective treatments.

METHODS

We performed a literature search using PubMed, Web of Science and Google Scholar databases using specified search terms for materials published using search terms. For each case, the type of block, the difficulty of the procedure, the dose of local anaesthetic, positivity of aspiration before and after the event, maternal outcome, Apgar score, onset of symptoms, cardiorespiratory and neurological manifestations, cardiorespiratory support employed, admission to an intensive care unit, cardiac arrest events and duration of mechanical ventilation were extracted.

RESULTS

A total of 605 cases were identified, of which 51 were sufficiently detailed for analysis. Although TSA is described after all neuraxial techniques, spinal after epidural was a particular concern in recent reports. Respiratory distress was universal but apnoea was not. The onset of apnoea was variable, ranging from 1 to 180 min. Hypotension was not invariable and occurred in approximately half of cases. Multiple fatalities and neurological injuries were reported, often in under-resourced areas when providers were not skilled in airway management or when recognition and intervention were delayed. In the most recent reports good outcomes were achieved when effective treatments were rapidly provided.

CONCLUSIONS

The available literature confirms that TSA remains an active clinical problem and that with prompt recognition and treatment good outcomes can be achieved. This requires anticipation and preparedness in all clinical areas where neuraxial techniques are performed.

Infectious complications following regional anesthesia: a narrative review and contemporary estimates of risk

INTRODUCTION

Infectious complications following regional anesthesia (RA) while rare, can be devastating. The objective of this review was to estimate the risk of infectious complications following central neuraxial blocks (CNB) such as epidural anesthesia (EA), spinal anesthesia (SA) and combined spinal epidural (CSE), and peripheral nerve blocks (PNB).

MATERIALS AND METHODS

A literature search was conducted in PubMed, Embase and Cochrane databases to identify reference studies reporting infectious complications in the context of RA subtypes. Both prospective and retrospective studies providing incidence of infectious complications were included for review to provide pooled estimates (with 95% CI). Additionally, we explored incidences specifically associated with spinal anesthesia, incidences of central nervous system (CNS) infections and, the incidences of overall and CNS infections following CNB in obstetric population.

RESULTS

The pooled estimate of overall infectious complications following all CNB was 9/100 000 (95% CI: 5, 13/100 000). CNS infections following all CNB was estimated to be 2/100 000 (95% CI: 1, 3/100 000) and even rarer following SA (1/100 000 (95% CI: 1, 2/100 000)). Obstetric population had a lower rate of overall (1/100 000 (95% CI: 1, 3/100 000)) and CNS infections (4 per million (95% CI: 0.3, 1/100 000)) following all CNB. For PNB catheters, the reported rate of infectious complications was 1.8% (95% CI: 1.2, 2.5/100).

DISCUSSION

Our review suggests that the risk of overall infectious complications following neuraxial anesthesia is very rare and the rate of CNS infections is even rarer. The infectious complications following PNB catheters seems significantly higher compared with CNB. Standardizing nomenclature and better reporting methodologies are needed for the better estimation of the infectious complications.

Computerised modified paramedian approach technique versus conventional midline approach technique of lumbar puncture: a randomised control trial protocol

INTRODUCTION

The lumbar puncture (LP) technique is widely used for diagnostic and therapeutic purposes. In recent years, the paramedian approach technique (PAT) has gained increasing interest due to its advantages over the conventional midline approach technique (MAT) that has been traditionally employed in clinical practice for LP. However, there have been inconsistent discussions regarding the efficacy of different LP techniques. Based on digital virtual human and computer simulation techniques, a new approach called computerised modified PAT (CMPAT) was proposed. Therefore, the aim of this study is to discuss a randomised controlled trial (RCT) protocol to investigate and compare the effects of CMPAT and MAT in patients undergoing LP.

METHODS AND ANALYSIS

We will conduct a prospective, multicentre RCT. The study will recruit 84 patients aged 18-99 years who require LP. Participants will be randomly assigned to either the CMPAT treatment group (group A) or the MAT treatment group (group B). The primary outcome measure will be the number of needle insertion attempts required for a successful LP. Secondary outcomes will include the puncture success rate, pain assessment in the back, head, and legs, and the occurrence of complications. The measurement of these secondary outcomes will be taken during the procedure, as well as at specific time points: 30 min, 6 hours, 1 day, 3 days, 7 days, 2 weeks and 4 weeks after the procedure. Pain levels will be assessed using a Numerical Rating Scale.

ETHICS AND DISSEMINATION

Ethical approval (2022YF052-01) has been obtained from the Ethics Committee of Fujian Medical University Union Hospital, Fuzhou, China. The research findings will be published in an international peer-reviewed scientific journal and presented at scientific conferences.

TRIAL REGISTRATION NUMBER

ChiCTR2300067937.

Posterior quadratus lumborum block versus epidural analgesia for postoperative pain management after open radical cystectomy: A randomized clinical trial

BACKGROUND

In open abdominal surgery, continuous epidural analgesia is commonly used method for postoperative analgesia. However, ultrasound (US)-guided fascial plane blocks may be a reasonable alternative.

METHODS

In this randomized controlled trial, we compared posterior quadratus lumborum block (QLB) with epidural analgesia for postoperative pain after open radical cystectomy (ORC). Adult patients aged 18-85 with bladder cancer (BC) scheduled for open RC were randomized in two groups. Exclusion criteria were complicated diabetes mellitus type I, lack of cooperation, and persistent pain for reasons other than BC. In one group, a bilateral US-guided single injection posterior QLB was performed with 3.75 mg/ml ropivacaine 20 ml/side. In the other group, continuous epidural analgesia with ropivacaine was used. Basic analgesia was oral paracetamol 1000 mg three times daily, and long-acting opioid twice daily in both groups. All patients had patient-controlled rescue analgesia with oxycodone. Postoperative cumulative rescue opioid consumption was recorded for the day of surgery, and the following 2 postoperative days (POD 0-2). Secondary outcomes were postoperative pain and nausea and vomiting.

RESULTS

In total, 20 patients (QLB), and 19 patients (epidural analgesia) groups, were included in the analyses. Cumulative rescue opioid consumption on POD 0, being of duration 9-12 h, was 14 mg (7.6-33.3) in the QLB group versus 6.1 mg (2.0-16.1) in the epidural analgesia group, p = 0.089, and as doses, 8 doses (3.6-15.7) versus 4 doses (1.3-8.5), p = .057. On POD 1 consumption was 25.3 mg (11.0-52.9) versus 18.0 mg (14.4-43.7), p = .749, and as doses 12 (5.5-23.0) versus 10 (8-20), p > .9, respectively. On POD 2 consumption was 19.1 mg (7.9-31.0) versus 18.0 mg (5.4-27.6) p = .749, and as doses 8.5 (5.2-14.7) versus 11 (3.0-18.0) p > .9, respectively.

CONCLUSION

Opioid consumption did not differ significantly between posterior QLB and an epidural infusion with ropivacaine for the first 2 postoperative days following RC.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT03328988.

Labor epidural analgesia and subsequent risk of offspring autism spectrum disorder and attention-deficit/hyperactivity disorder: a cross-national cohort study of 4.5 million individuals and their siblings

BACKGROUND

A recent study has suggested that labor epidural analgesia may be associated with increased rates of offspring autism spectrum disorder. Subsequent replication attempts have lacked sufficient power to confidently exclude the possibility of a small effect, and the causal nature of this association remains unknown.

OBJECTIVE

This study aimed to investigate the extent to which exposure to labor epidural analgesia is associated with offspring autism spectrum disorder and attention-deficit/hyperactivity disorder following adjustments for unmeasured familial confounding.

STUDY DESIGN

We identified 4,498,462 singletons and their parents using the Medical Birth Registers in Finland (cohorts born from 1987-2005), Norway (1999-2015), and Sweden (1987-2011) linked with population and patient registries. These cohorts were followed from birth until they either had the outcomes of interest, emigrated, died, or reached the end of the follow-up (at mean ages 13.6-16.8 years), whichever occurred first. Cox regression models were used to estimate country-specific associations between labor epidural analgesia recorded at birth and outcomes (eg, at least 1 secondary care diagnosis of autism spectrum disorder and attention-deficit/hyperactivity disorder or at least 1 dispensed prescription of medication used for the treatment of attention-deficit/hyperactivity disorder). The models were adjusted for sex, birth year, birth order, and unmeasured familial confounders via sibling comparisons. Pooled estimates across all the 3 countries were estimated using inverse variance weighted fixed-effects meta-analysis models.

RESULTS

A total of 4,498,462 individuals (48.7% female) were included, 1,091,846 (24.3%) of which were exposed to labor epidural analgesia. Of these, 1.2% were diagnosed with autism spectrum disorder and 4.0% with attention-deficit/hyperactivity disorder. On the population level, pooled estimates showed that labor epidural analgesia was associated with increased risk of offspring autism spectrum disorder (adjusted hazard ratio, 1.12; 95% confidence interval, 1.10-1.14, absolute risks, 1.20% vs 1.07%) and attention-deficit/hyperactivity disorder (adjusted hazard ratio, 1.20; 95% confidence interval, 1.19-1.21; absolute risks, 3.95% vs 3.32%). However, when comparing full siblings who were differentially exposed to labor epidural analgesia, the associations were fully attenuated for both conditions with narrow confidence intervals (adjusted hazard ratio [autism spectrum disorder], 0.98; 95% confidence interval, 0.93-1.03; adjusted hazard ratio attention-deficit/hyperactivity disorder, 0.99; 95% confidence interval, 0.96-1.02).

CONCLUSION

In this large cross-national study, we found no support for the hypothesis that exposure to labor epidural analgesia causes either offspring autism spectrum disorder or attention-deficit/hyperactivity disorder.

The leptomeninges as a critical organ for normal CNS development and function: First patient and public involved systematic review of arachnoiditis (chronic meningitis)

BACKGROUND & IMPORTANCE

This patient and public-involved systematic review originally focused on arachnoiditis, a supposedly rare "iatrogenic chronic meningitis" causing permanent neurologic damage and intractable pain. We sought to prove disease existence, causation, symptoms, and inform future directions. After 63 terms for the same pathology were found, the study was renamed Diseases of the Leptomeninges (DLMs). We present results that nullify traditional clinical thinking about DLMs, answer study questions, and create a unified path forward.

METHODS

The prospective PRISMA protocol is published at Arcsology.org. We used four platforms, 10 sources, extraction software, and critical review with ≥2 researchers at each phase. All human sources to 12/6/2020 were eligible for qualitative synthesis utilizing R. Weekly updates since cutoff strengthen conclusions.

RESULTS

Included were 887/14286 sources containing 12721 DLMs patients. Pathology involves the subarachnoid space (SAS) and pia. DLMs occurred in all countries as a contributor to the top 10 causes of disability-adjusted life years lost, with communicable diseases (CDs) predominating. In the USA, the ratio of CDs to iatrogenic causes is 2.4:1, contradicting arachnoiditis literature. Spinal fusion surgery comprised 54.7% of the iatrogenic category, with rhBMP-2 resulting in 2.4x more DLMs than no use (p<0.0001). Spinal injections and neuraxial anesthesia procedures cause 1.1%, and 0.2% permanent DLMs, respectively. Syringomyelia, hydrocephalus, and arachnoid cysts are complications caused by blocked CSF flow. CNS neuron death occurs due to insufficient arterial supply from compromised vasculature and nerves traversing the SAS. Contrast MRI is currently the diagnostic test of choice. Lack of radiologist recognition is problematic.

DISCUSSION & CONCLUSION

DLMs are common. The LM clinically functions as an organ with critical CNS-sustaining roles involving the SAS-pia structure, enclosed cells, lymphatics, and biologic pathways. Cases involve all specialties. Causes are numerous, symptoms predictable, and outcomes dependent on time to treatment and extent of residual SAS damage. An international disease classification and possible treatment trials are proposed.

Spinal anesthesia and hypotensive events in hip fracture surgical repair in elderly patients: a meta-analysis

BACKGROUND

Spinal anesthesia (SA) is widely used for anesthetic management of patients undergoing hip surgery, and hypotension is the most common cardiovascular side effect of SA. This paper aims to assess the lowest effective dose of SA that reduces the occurrence of intraoperative hypotension in elderly patients scheduled for major lower limb orthopedic surgery.

METHODS

We conducted a systematic review of randomized controlled trials (RCTs) performed in elderly patients scheduled for surgical hip repair and a meta-analysis with meta-regression on the occurrence of hypotensive episodes at different effective doses of anesthetics. We searched PUBMED®, EMBASE®, and the Cochrane Controlled Clinical trials registered.

RESULTS

Our search retrieved 2085 titles, and after screening, 6 were finally included in both the qualitative and quantitative analysis, including 344 patients [15% (10-28) males], with a median (25th to 75th interquartile) age of 82 (80-85). The risk of bias assessment reported "low risk" for 5 (83.3%) and "some concerns" for 1 (16.7%) of the included RCTs. The low dose of SA of [mean 6.5 mg (1.9)] anesthetic was associated with a lower incidence of hypotension [OR = 0.09 (95%CI 0.04-0.21); p = 0.04; I² = 56.9%], as compared to the high-dose of anesthetic [mean 10.5 mg (2.4)].

CONCLUSIONS

In the included studies of this meta-analysis, a mean dose of 6.5 mg of SA was effective in producing intraoperative comfort and motor block and associated with a lower incidence of hypotension as compared to a mean dose of 10.5 mg.

TRIAL REGISTRATION

CRD42020193627.

Feasibility of continuous epidural analgesia in patients with failed back surgery syndrome and spinal stenosis

PURPOSE

The purpose of this study was to outline the feasibility of continuous epidural analgesia in the treatment of failed back surgery syndrome (FBSS) or spinal stenosis.

METHODS

We queried our prospective collected institutional database to include all consecutive patients, who underwent continuous epidural analgesia with accompanying intensive physiotherapeutic exercise within a timeframe of 4 years. Patients suffered from FBSS or spinal stenosis; protocolled continuous epidural analgesia was planned for 4 days within the framework of an inpatient multimodal pain therapy concept. The instillation technique of the epidural catheter, the capability to attend in accompanying physiotherapy, and the peri-interventional complications were evaluated.

RESULTS

153 patients with an average age of 57.4 years (± 11.9) were enrolled in this study. 105 patients suffered from FBSS and 48 patients had spinal stenosis. Overall, 148 patients (96.7%) reported the pain reduction and were able to perform daily intensified physiotherapeutic exercise. There were no serious adverse events, neither infection nor bleeding, no cardiopulmonary complication or permanent neurological deficits. The most common side effect was neurological impairment, such as numbness, dysesthesia, or weakness of the lower limbs with complete regression after flow rate adjustment. Patients with FBSS were more likely to develop dysesthesia (p = 0.007).

CONCLUSIONS

Continuous epidural analgesia is feasible in patients with FBSS or spinal stenosis. This treatment enables extensive physiotherapeutic treatment even in patients with severe pain conditions and can be considered as an alternative to epidural injections. An increased complication rate in comparison to short-term perioperative or perinatal application was not observed.

Efficacy of Perioperative Continuous Intravenous Lidocaine Infusion for 72 Hours on Postoperative Pain and Recovery in Patients Undergoing Hepatectomy: Study Protocol for a Prospective Randomized Controlled Trial

Purpose

Many patients develop severe and persistent pain after hepatectomy delaying postoperative rehabilitation. Studies have suggested that intravenous lidocaine infusion relieved postoperative pain and improved overall postoperative outcomes. However, its efficacy on hepatectomy is still masked, due to the postoperative metabolic change of lidocaine by the liver. We hypothesized that intravenous lidocaine infusion in the perioperative period would lead to postoperative pain reduction and improve the overall patient experience.

Study Design and Methods

In this prospective double-blind, randomized controlled design trial, 260 adults scheduled for hepatectomy will be allocated to the lidocaine and the placebo groups. The lidocaine group will be administered lidocaine intravenously during intraoperative period and 72 postoperative hours; the placebo group will be administered normal saline at the same volume, infusion rate, and timing. The primary outcome is the incidence of moderate-severe pain (numeric rating scale ≥4) during movement at 24 hours after surgery. The secondary outcomes include the incidence of moderate-severe pain at 24 hours after surgery at rest, the incidence of moderate-severe pain at 48 and 72 hours after surgery at rest and during movement, the cumulative morphine consumption at 24, 48 and 72 hours postoperatively, bowel function recovery, the incidence of postoperative nausea and vomiting, the incidence of postoperative pulmonary complications, the length of hospital stay, levels of inflammatory factors and patient satisfaction scores.

Discussion

This is the first prospective trial to shed light on the efficacy of intraoperative period and 72 postoperative hours intravenous lidocaine on postoperative pain and recovery after hepatectomy. The findings will provide a new strategy of perioperative pain management for hepatectomy.

Major neurological complications following central neuraxial blockade - A multicentre pilot study in Aurangabad city (MGMA CNB Study)

Background and Aims

Incidence of major neurological complications following central neuraxial blockade (CNB) in India is not known. This information is essential for explaining risk preoperatively to patients and for medico-legal purposes. This study was undertaken to assess feasibility (recruitment process, protocol adherence, resources mobilisation, data management and evaluation of scientific outcome) for planning multicentric studies on major neurological complications following CNB at state/national level.

Methods

This was a hospital-based, multicentre pilot study, with cross-sectional and follow-up components. Patients receiving CNB either perioperatively or during acute/chronic pain management were included in the study. Thirty-six randomly selected tertiary and nontertiary care institutes were included. Details of demographic information, CNB procedure and major neurological complications were collected anonymously via online tools. Feedback about study feasibility was collected from participating anaesthesiologists and study team.

Results

Selected institutes continued participation throughout study period. About 99.98% of eligible patients were enroled. Complete data collection of 8053 patients and analysis was possible. Regular reminders from study coordinators helped to optimise data collection. Tertiary care institutes contributed to 74.50% of data. About 64.96% patients were females. Spinal anaesthesia was the most frequently used neuraxial block (93.41%). Bupivacaine and adjuvant were used in 95.53% and 16.5% patients, respectively. Two patients developed cardiac arrest and cause-effect relationship with CNB was established. Participants' recruitment, protocol adherence, resources mobilisation, data management and evaluation of scientific outcomes were feasible.

Conclusion

A multicentre state/nationwide study can be conducted based on this first-of-its-kind pilot study in India.

Cohort study of hospitalists' procedural skills: baseline competence and durability after simulation-based training

OBJECTIVES

Hospitalists are expected to be competent in performing bedside procedures, which are associated with significant morbidity and mortality. A national decline in procedures performed by hospitalists has prompted questions about their procedural competency. Additionally, though simulation-based mastery learning (SBML) has been shown to be effective among trainees whether this approach has enduring benefits for independent practitioners who already have experience is unknown. We aimed to assess the baseline procedural skill of hospitalists already credentialed to perform procedures. We hypothesised that simulation-based training of hospitalists would result in durable skill gains after several months.

DESIGN

Prospective cohort study with pretraining and post-training measurements.

SETTING

Single, large, urban academic medical centre in the USA.

PARTICIPANTS

Twenty-two out of 38 eligible participants defined as hospitalists working on teaching services where they would supervise trainees performing procedures.

INTERVENTIONS

One-on-one, 60 min SBML of lumbar puncture (LP) and abdominal paracentesis (AP).

PRIMARY AND SECONDARY OUTCOME MEASURES

Our primary outcome was the percentage of hospitalists obtaining minimum passing scores (MPS) on LP and AP checklists; our secondary outcomes were average checklist scores and self-reported confidence.

RESULTS

At baseline, only 16% hospitalists met or exceeded the MPS for LP and 32% for AP. Immediately after SBML, 100% of hospitalists reached this threshold. Reassessment an average of 7 months later revealed that only 40% of hospitalists achieved the MPS. Confidence increased initially after training but declined over time.

CONCLUSIONS

Hospitalists may be performing invasive bedside procedures without demonstration of adequate skill. A single evidence-based training intervention was insufficient to sustain skills for the majority of hospitalists over a short period of time. More stringent practices for certifying hospitalists who perform risky procedures are warranted, as well as mechanisms to support skill maintenance, such as periodic simulation-based training and assessment.

Narrative review of neuraxial potassium chloride administration errors: clinical features, human factors, and prevention measures

BACKGROUND

Administration of the wrong drug via the epidural or intrathecal route can cause devastating consequences. Because of the commonality of potassium replacement therapy coupled to its potential neurotoxic profile, we suspected that injuries related to this drug error would be present in the literature.

OBJECTIVES

We aimed to identify clinical characteristics associated with the inadvertent administration of potassium chloride (KCl) during neuraxial anesthesia. Our secondary objective was to identify human factors that may have been associated.

EVIDENCE REVIEW

Published reports of neuraxial administration of KCl in humans were searched using Medline and Google Scholar. Error reports in any language were included.

FINDINGS

25 case reports/series reported administration of KCl via epidural (25 patients) or intrathecal routes (three patients). There were six cases during interventional pain procedures, five cases in operating rooms and 17 in wards or intensive care units. Neuraxial KCl caused paraplegia in 22 patients. Mechanical ventilation was instituted in 11 of 28 patients. Three patients died. Epidural (eight patients) and spinal (two patients) lavage were performed to minimize consequences. A correctly prepared KCl infusion was connected to the epidural catheter for nine patients on wards (32%; 95% upper confidence limit: 48%) due to epidural-intravenous line confusion. Among the other 19 errors, KCl was confused with normal saline for 13 patients or local anesthetic in three patients. A wide range of concentrations and doses of KCl were administered. Variable use of intravenous steroid (13 patients) and epidural saline (eight patients) was found among patients who received epidural KCl. Human factors identified included incorrect visual perception, inadequate monitoring of infusions and substandard practice related to neuraxial anesthesia or analgesia.

CONCLUSIONS

KCl administration via epidural or intrathecal route has been reported to cause catastrophic consequences.

Spinal subdural hematoma and subdural anesthesia following combined spinal-epidural anesthesia: a case report

Background

Subdural anesthesia and spinal subdural hematoma are rare complications of combined spinal-epidural anesthesia. We present a patient who developed both after multiple attempts to achieve combined spinal–epidural anesthesia.

Case presentation

A 21-year-old parturient, gravida 1, para 1, with twin pregnancy at gestational age 34^+ 5 weeks underwent cesarean delivery. Routine combined spinal–epidural anesthesia was planned; however, no cerebrospinal fluid outflow was achieved after several attempts. Bupivacaine (2.5 mL) administered via a spinal needle only achieved asymmetric blockade of the lower extremities, reaching T12. Then, epidural administration of low-dose 2-chlorprocaine caused unexpected blockade above T2 as well as tinnitus, dyspnea, and inability to speak. The patient was intubated, and the twins were delivered. Ten minutes after the operation, the patient was awake with normal tidal volume. The endotracheal tube was removed, and she was transferred to the intensive care unit for further observation. Postoperative magnetic resonance imaging suggested a spinal subdural hematoma extending from T12 to the cauda equina. Sensory and motor function completely recovered 5 h after surgery. She denied headache, low back pain, or other neurologic deficit. The patient was discharged 6 days after surgery. One month later, repeat MRI was normal.

Conclusions

All anesthesiologists should be aware of the possibility of SSDH and subdural block when performing neuraxial anesthesia, especially in patients in whom puncture is difficult. Less traumatic methods of achieving anesthesia, such as epidural anesthesia, single-shot spinal anesthesia, or general anesthesia should be considered in these patients. Furthermore, vital signs and neurologic function should be closely monitored during and after surgery.

Assessment of main complications of regional anesthesia recorded in an acute pain unit in a tertiary care university hospital: a retrospective cohort

Background

Regional anesthesia has been increasingly used. Despite its low number of complications, they are associated with relevant morbidity. This study aims to evaluate the incidence of complications after neuraxial block and peripheral nerve block.

Methods

A retrospective cohort study was conducted, and data related to patients submitted to neuraxial block and peripheral nerve block at a tertiary university hospital from January 1, 2011 to December 31, 2017 were analyzed.

Results

From 10,838 patients referred to Acute Pain Unit, 1093(10.1%) had side effects or complications: 1039 (11.4%) submitted to neuraxial block and 54 (5.2%) to peripheral nerve block. The most common side effects after neuraxial block were sensory (48.5%) or motor deficits (11.8%), nausea or vomiting (17.5%) and pruritus (8.0%); The most common complications: 3 (0.03%) subcutaneous cell tissue hematoma, 3 (0.03%) epidural abscesses and 1 (0.01%) arachnoiditis. 204 of these patients presented sensory or motor deficits at hospital discharge and needed follow-up. Permanent peripheral nerve injury after neuraxial block had an incidence of 7.7:10,000 (0.08%). The most common side effects after peripheral nerve block were sensory deficits (52%) and 21 patients maintained follow-up due to symptoms persistence after hospital discharge.

Conclusion

Although we found similar incidences of side effects or even lower than those described, major complications after neuraxial block had a higher incidence, particularly epidural abscesses. Despite this, other serious complications, such as spinal hematoma and permanent peripheral nerve injury, are still rare.

Intracranial hematoma and abscess after neuraxial analgesia and anesthesia: a review of the literature describing 297 cases

BACKGROUND

Besides spinal complications, intracranial hematoma or abscess may occur after neuraxial block. Risk factors and outcome remain unclear.

OBJECTIVE

This review evaluates characteristics, treatment and recovery of patients with intracranial complications after neuraxial block.

EVIDENCE REVIEW

We systematically searched MEDLINE, Embase and the Cochrane Library from their inception to May 2020 for case reports/series, cohort studies and reviews of intracranial hematoma or abscess associated with neuraxial block. Quality of evidence was assessed using the critical appraisal of a case study checklist by Crombie.

FINDINGS

We analyzed 232 reports, including 291 patients with hematoma and six patients with abscess/empyema. The major part of included studies comprised single case reports with a high risk of bias. Of the patients with hematoma, 48% concerned obstetric patients, the remainder received neuraxial block for various perioperative indications or pain management. Prior dural puncture was reported in 81%, either intended (eg, spinal anesthesia) or unintended (eg, complicated epidural catheter placement). Headache was described in 217 patients; in 101 patients, symptoms resembled postdural puncture headache (PDPH). After treatment, 11% had partial or no recovery and 8% died, indicating the severity of this complication. Intracranial abscess after neuraxial block is seldom reported; six reports were found.

CONCLUSION

Diagnosis of intracranial hematoma is often missed initially, as headache is assumed to be caused by cerebrospinal hypotension due to cerebrospinal fluid leakage, known as PDPH. Prolonged headache without improvement, worsening symptoms despite treatment or epidural blood patch, change of headache from postural to non-postural or new neurological signs should alert physicians to alternative diagnoses.

Spinal subarachnoid haematoma after neuraxial anaesthesia in a patient with polycythaemia vera

Polycythaemia vera is a common haematological proliferative disorder. It is characterised by uncontrolled red cell production with ensuing peri-operative vaso-occlusive and haemorrhagic complications. Spinal haematoma after neuraxial anaesthesia is rare; most cases are associated with technical difficulties or bleeding disorders. Current consensus opinion suggests that neuraxial anaesthesia in patients with polycythaemia vera is safe due to a lower risk of thrombotic events and hypoxaemia compared with general anaesthesia. We report a case of a spinal subarachnoid haematoma after uneventful neuraxial anaesthesia in a patient with optimised polycythaemia vera. Despite an emergent laminectomy, the patient developed permanent motor deficits. This report highlights that although neuraxial anaesthesia is recommended by many authors, patients with polycythaemia vera can paradoxically have an increased haemorrhagic risk from platelet dysfunction and acquired von Willebrand disease. Clinicians proceeding with surgery under neuraxial anaesthesia should appreciate these risks even in patients with normal or apparently elevated thrombotic states. This case also demonstrates that traditional coagulation tests may need to be complemented by pre-operative platelet function tests and screening for von Willebrand disease. Finally, the importance of the patient participation in the choice of the anaesthesia technique cannot be understated, with specific attention paid to this frequently unrecognised risk.

Epidural analgesia for postoperative pain: Improving outcomes or adding risks?

Current evidence shows that the benefits of epidural analgesia (EA) are not as impressive as believed in the past, while the risks of adverse effects and serious complications are greater than previously estimated. There are many reasons for the decreasing role of epidural technique in clinical practice (table). Indeed, EA can cause harm and hinder early mobilization in enhanced recovery after surgery (ERAS) programmes. Some ERAS interventions are complex, confusing, sometimes contradictory and apparently unimplementable. In spite of much hype and after almost 25 years, the originator of the concept has described the current status of ERAS as 'far from good'. Outpatient surgery setup has been a remarkable success for many major surgical procedures, and it predates ERAS and appears to be a simpler and better model for reducing postoperative morbidity and hospitalization times. Systematic reviews of comparative studies have shown that less invasive and safer but equally effective alternatives to EA are available for almost all major surgical procedures. These include: paravertebral block, peripheral nerve blocks, catheter wound infusion, periarticular local infiltration analgesia, preperitoneal catheters and transversus abdominis plane block. Increasingly, these non-EA methods are being used as surgeon-delivered regional analgesia (RA) techniques. This encouraging trend of active surgeon participation, with anaesthesiologist collaboration, will undoubtedly improve the decades-old twin problems of underused RA techniques and undertreated postoperative pain. The continued use of EA at any institution can only be justified by results from its own audits; however, regrettably only very few institutions perform such regular audits.

Lumbar drains: Practical understanding and application for the otolaryngologist

INTRODUCTION

Lumbar drains are frequently used in patients with otolaryngologic concerns. These can be used therapeutically or prophylactically with the primary purpose being to modulate CSF pressure. Within otolaryngology, lumbar drains are most frequently used for cerebrospinal fluid leaks - either due to cerebrospinal fluid fistulas or in skull base surgery as these allow for potential healing of the defect. While not typically placed by otolaryngologists, a basic understanding of lumbar drains is beneficial in the context of patient management.

MANAGEMENT

A lumbar drain is inserted into the intrathecal space in a patient's lumbar spine. Though considered to be a benign procedure, complications are relatively frequent, and adjustment or replacement of the drain may be required. Complications include infection, epidural bleeding, retained hardware, sequelae of relative immobility, or may relate to over-drainage, ranging from mild headache to cranial neuropathies, altered mental status, pneumocephalus, intracranial hemorrhage, and death. While in place, neurologic exams should be performed routinely and should include motor and sensory exams of the lower extremities. A patient should be monitored for fevers, nuchal rigidity, and other signs of infection or meningitis. The CSF fluid should be grossly examined to identify changes, but routine laboratory tests are not typically run on the fluid itself. Drainage rates will vary usually between 5 and 20 mL per hour and must be frequently reassessed and adjusted based upon signs of intracranial hypotension. Drains should be removed when appropriate and should not be left in more than 5 days due to the increased infectious risk.

CONCLUSION

Lumbar drains are important tools used in patients with otolaryngologic pathologies. Otolaryngologists and otolaryngology residents should be familiar with these catheters to determine if they are working correctly and to identify adverse effects as early as possible.

Spinal epidural hematoma and abscess after neuraxial anesthesia: a historical cohort study using the Japanese Diagnosis Procedure Combination database

BACKGROUND

Spinal epidural hematoma and abscess are rare complications of neuraxial anesthesia but can cause severe neurologic deficits. The incidence of these complications vary widely in existing studies and the risk factors remain uncertain. We estimated the incidence of these complications and explored associations using a national inpatient database in Japan.

METHODS

Using Japanese Diagnosis Procedure Combination data on surgical inpatients who underwent neuraxial anesthesia from July 2010 to March 2017, we identified patients with spinal epidural hematoma and/or abscess. We investigated age, sex, Charlson comorbidity index, antithrombotic therapy, type of surgery, admission, and hospital for association with these complications. The incidences of spinal epidural hematoma and abscess were estimated separately, and a nested case-control study was performed to examine factors associated with these complications.

RESULTS

We identified 139 patients with spinal epidural hematoma and/or abscess among 3,833,620 surgical patients undergoing neuraxial anesthesia. The incidences of spinal epidural hematoma and abscess were 27 (95% confidence interval [CI], 22 to 32) and 10 (7 to 13) per one million patients, respectively. Spinal anesthesia was associated with significantly fewer complications compared with epidural or combined spinal epidural anesthesia (odds ratio, 0.15; 95% CI, 0.08 to 0.32). Antiplatelet agent (odds ratio, 0.49; 95% CI, 0.06 to 3.91) and anticoagulants (odds ratio, 1.65; 95% CI, 0.95 to 2.85) were not significantly associated with these complications.

CONCLUSIONS

This analysis identified the incidences of spinal epidural hematoma and/or abscess after neuraxial anesthesia. Additional large-scale studies are warranted to examine the incidences and factors associated with these complications.

Incidence and Factors Contributing to Low Back Pain in the Nonobstetrical Patients Operated Under Spinal Anesthesia: A Prospective 1-Year Follow-Up Study

PURPOSE

To determine the incidence and factors contributing to postspinal anesthesia (SPA) low back pain (LBP) in patients undergoing nonobstetrical surgeries.

DESIGN

A prospective 1-year follow-up study.

METHODS

Patients having nonobstetrical surgery using SPA were included. The patients were followed up through phone calls and interviews every postoperative day for the first week, weekly for a month, and then monthly for a year after SPA. Patients' duration of LBP, duration of surgery, and need for LBP treatment were recorded.

FINDINGS

Of 410 patients, 5.8% (24 patients) experienced LBP. The incidence of LBP did not have a significant correlation with the recorded variables (P > .05). There was a negative significant correlation between duration of LBP and duration of surgery (r = -0.5096; P = .001). Of the 24 patients experiencing LBP, 16.7% (four patients) experienced it for less than 1 day, 66.7% (16 patients) 1 to 7 days, 16.7% (four patients) more than 7 days, and only one patient (4.2%) for up to 17 days. Special LBP treatment was not needed in any of the patients.

CONCLUSIONS

The incidence of LBP was very low, and those patients undergoing nonobstetrical surgery and receiving SPA did not experience persistent LBP.

Regional Nerve Blocks-Best Practice Strategies for Reduction in Complications and Comprehensive Review

PURPOSE OF REVIEW

Understanding the etiologies of the complications associated with regional anesthesia and implementing methods to reduce their occurrence provides an opportunity to foster safer practices in the delivery of regional anesthesia.

RECENT FINDINGS

Neurologic injuries following peripheral nerve block (PNB) and neuraxial blocks are rare, with most being transient. However, long-lasting and devastating sequelae can occur with regional anesthesia. Risk factors for neurologic injury following PNB include type of block, injection in the presence of deep sedation or general anesthesia, presence of existing neuropathy, mechanical trauma from the needle, pressure injury, intraneural injection, neuronal ischemia, iatrogenic injury related to surgery, and local anesthetic neurotoxicity. The present investigation discusses regional blocks, complications of regional blocks, risk factors, site-specific limitations, specific complications and how to prevent them from happening, avoiding complications in regional anesthesia, and the future of regional anesthesia.

Incidence and related factors for intraoperative failed spinal anaesthesia for lower limb arthroplasty

BACKGROUND

Spinal anaesthesia is the preferred choice for total hip- and knee arthroplasty (THA/TKA), due to the claimed superior outcome profile, relative simple technique and without the need for advanced airway support. However, choosing and informing about spinal anaesthesia should also include the risk for intraoperative failed spinal anaesthesia with associated pain, discomfort and suboptimal settings for airway management. Small-scale studies suggest incidences from 1 to 17%; however, no multi-institutional large data exists on failed spinal incidence and related factors during THA/TKA, hindering evidence-based information and potential anaesthesia stratification.

METHODS

In a sub-analysis, data from a prospective study on spinal anaesthesia for THA/TKA were examined for incidence of intraoperative conversion to general anaesthesia. Potential perioperative factors (age, gender, American Society of Anaesthesiologist (ASA) score, height, weight, BMI, procedure, bupivacaine dosage and duration of time from spinal administration until end of surgery) were analysed with logistic regression for relation to failed spinal anaesthesia.

RESULTS

In all, 1451 patients were included for analysis, whereof 57 (3.9%) had failed spinal anaesthesia. Spinal failure patients were significantly younger (61 vs. 67 years, P = 0.003), and operation time longer in the failed spinal group vs no-failure, respectively (133 vs. 89 min, P < 0.001). No significant differences were found with regard to bupivacaine volume, gender, ASA-score, height, weight, BMI or THA vs. TKA.

CONCLUSION

Failed spinal anaesthesia for THA and TKA is a relatively frequent occurrence and identification of risk patients is not feasible. These results should be considered when choosing anaesthesia and included in the information to patients.

Effects of epidural anesthesia on postoperative nausea and vomiting in laparoscopic gynecological surgery: a randomized controlled trial

PURPOSE

Patients undergoing laparoscopic gynecological surgery are susceptible to postoperative nausea and vomiting (PONV). We hypothesized that a combination of epidural and general anesthesia to minimize intraoperative opioid administration would reduce the incidence of PONV following laparoscopic gynecological surgery.

METHODS

Women undergoing elective laparoscopic gynecological surgery were randomly assigned to receive general anesthesia alone (group G, n = 45) or general anesthesia with epidural anesthesia (group GE, n = 45). Patients in group G received fentanyl and remifentanil for intraoperative analgesia, and those in group GE received single-shot ropivacaine at the time of induction of anesthesia. The primary outcome was the incidence of PONV within 24 h of surgery. Secondary outcomes included the use of rescue metoclopramide within 24 h of surgery and the time to first incidence of PONV and first use of rescue metoclopramide.

RESULTS

The incidence of PONV within 24 h of surgery was 60.0% in group G and 44.4% in group GE [relative risk (RR): 0.53, 95% confidence interval (CI): 0.23-1.23, p = 0.14]. There were no intergroup differences in the use of rescue metoclopramide (40.0% in group G, 24.4% in group GE, RR: 0.49, 95% CI 0.20-1.20, p = 0.11) and the time to first incidence of PONV and first use of rescue metoclopramide (p = 0.20 and 0.12, respectively).

CONCLUSION

Minimizing intraoperative opioid administration by combining epidural and general anesthesia did not reduce the 24-h incidence of PONV or rescue metoclopramide use after laparoscopic gynecological surgery.

Multicenter cohort-study of 15326 cases analyzing patient satisfaction and perioperative pain management: general, regional and combination anesthesia in knee arthroplasty

Numbers of knee replacement surgeries have been rising over the past years. After having ameliorated operation techniques and material, pain management and anesthetic methods have come into focus. All 15326 patients included had undergone primary knee arthroplasty within this multicenter cohort-study, conducted in 46 orthopedic departments. Parameters were evaluated on first postoperative day. Primary outcome values were pain levels (activity, minimum and maximum pain, and pain management satisfaction). Pain medication necessity was analyzed. Parameters were compared between the types of anesthesia used: general, regional and combination anesthesia. Pain scores and pain management satisfaction were significantly better in the groups of either spinal or peripheral anesthesia combined with general anesthesia (p < 0.001, respectively). Patients who received the combination of general and spinal anesthesia were associated with the lowest need for opioids (p < 0.001). The use of a combined general and spinal anesthesia as well as using a combination of general and peripheral anesthesia in knee arthroplasty was associated with a highly significant advantage to other anesthetic techniques regarding perioperative pain management in daily clinical practice, but maybe below clinical relevance. Furthermore they were associated with positive tendency considering side effects and subjective well-being parameters.

Spinal or general anaesthesia for lower-limb amputation in peripheral artery disease - a retrospective cohort study

BACKGROUND

The present study aimed to determine which method of anaesthesia (spinal anaesthesia or general anaesthesia) is better in reducing post-operative analgesic requirements in patients undergoing major limb amputation for lower-limb ischaemia. Another aim was to find out if anaesthesiologists use neuraxial anaesthesia in high-risk patients despite abnormal coagulation profile or use of anticoagulation.

METHODS

The study was a retrospective cohort study. All patients undergone above-the-knee amputation or below-the-knee amputation due to peripheral artery disease between 1996 and 2010 were reviewed to evaluate post-operative opioid consumption and complications.

RESULTS

A total of 434 amputations in 323 patients were included in the study. The number of surgical complications, the need for surgical revision and the number of intensive care unit admissions were significantly higher in the general anaesthesia group. The need for post-operative opioid medication was significantly lower in patients with above-the-knee amputation and spinal anaesthesia. The use of post-operative epidural analgesia did not reduce analgesic requirements. In the present study, there were patients who received neuraxial anaesthesia despite abnormal coagulation profile or uninterrupted warfarin or clopidogrel. There were no reported cases of spinal or epidural haematoma.

CONCLUSION

Patients with spinal anaesthesia had a lower rate of surgical complications, re-operations and intensive care unit admissions. Patients with above-the-knee amputation and spinal anaesthesia had a lesser need for opioid medication in the post-operative period than patients with general anaesthesia. Anaesthesiologists performed neuraxial anaesthesia and/or analgesia in high-risk patients despite abnormal coagulation profile or ongoing anticoagulation, but no adverse outcomes were reported.

What Adverse Events and Injuries Are Cited in Anesthesia Malpractice Claims for Nonspine Orthopaedic Surgery?

BACKGROUND

Malpractice claims that arise during the perioperative care of patients receiving orthopaedic procedures will frequently involve both orthopaedic surgeons and anesthesiologists. The Anesthesia Closed Claims database contains anesthesia malpractice claim data that can be used to investigate patient safety events arising during the care of orthopaedic patients and can provide insight into the medicolegal liability shared by the two specialties.

QUESTIONS/PURPOSES

(1) How do orthopaedic anesthetic malpractice claims differ from other anesthesia claims with regard to patient and case characteristics, common events and injuries, and liability profile? (2) What are the characteristics of patients who had neuraxial hematomas after spinal and epidural anesthesia for orthopaedic procedures? (3) What are the characteristics of patients who had orthopaedic anesthesia malpractice claims for central ischemic neurologic injury occurring during shoulder surgery in the beach chair position? (4) What are the characteristics of patients who had malpractice claims for respiratory depression and respiratory arrests in the postoperative period?

METHODS

The Anesthesia Closed Claims Project database was the source of data for this study. This national database derives data from a panel of liability companies (national and regional) and includes closed malpractice claims against anesthesiologists representing > 30% of practicing anesthesiologists in the United States from all types of practice settings (hospital, surgery centers, and offices). Claims for damage to teeth or dentures are not included in the database. Patient characteristics, type of anesthesia, damaging events, outcomes, and liability characteristics of anesthesia malpractice claims for events occurring in the years 2000 to 2013 related to nonspine orthopaedic surgery (n = 475) were compared with claims related to other procedures (n = 1592) with p < 0.05 as the criterion for statistical significance and two-tailed tests. Odds ratios and their 95% confidence intervals were calculated for all comparisons. Three types of claims involving high-impact injuries in patients undergoing nonspine orthopaedic surgery were identified through database query for in-depth descriptive review: neuraxial hematoma (n = 10), central ischemic neurologic injury in the beach chair position (n = 9), and injuries caused by postoperative respiratory depression (n = 23).

RESULTS

Nonspine orthopaedic anesthesia malpractice claims were more frequently associated with nerve injuries (125 of 475 [26%], odds ratio [OR] 2.12 [1.66-2.71]) and events arising from the use of regional anesthesia (125 of 475 [26%], OR 6.18 (4.59-8.32) than in malpractice claims in other areas of anesthesia malpractice (230 of 1592 [14%] and 87 of 1592 [6%], respectively, p < 0.001 for both comparisons). Ninety percent (nine of 10) of patients with claims for neuraxial hematomas were receiving anticoagulant medication and all had severe long-term injuries, most with a history of significant delay in diagnosis and treatment after first appearance of signs and symptoms. Central ischemic injuries occurring during orthopaedic surgery in the beach chair position did not occur solely in patients who would have been considered at high risk for ischemic stroke. Patients with malpractice claims for injuries resulting from postoperative respiratory depression events had undergone lower extremity procedures (20 of 23 [87%]) and most events (22 of 23 [96%]) occurred on the day of surgery or the first postoperative day.

CONCLUSIONS

Nonspine orthopaedic anesthesia malpractice claims more frequently cited nerve injury and events arising from the use of regional anesthesia than other surgical anesthesia malpractice claims. This may reflect the frequency of regional anesthesia in orthopaedic cases rather than increased risk of injury associated with regional techniques. When neuraxial procedures and anticoagulation regimens are used concurrently, care pathways should emphasize clear lines of responsibility for coordination of care and early investigation of any unusual neurologic findings that might indicate neuraxial hematoma. We do not have a good understanding of the factors that render some patients vulnerable to the rare occurrence of intraoperative central ischemic injury in the beach chair position, but providers should carefully calculate cerebral perfusion pressure relative to measured blood pressure for patients in the upright position. Postoperative use of multiple opioids by different concurrent modes of administration warrant special precautions with consideration given to the provision of care in settings with enhanced respiratory monitoring. The limitations of retrospective closed claims database review prevent conclusions regarding causation. Nonetheless, the collection of relatively rare events with substantial clinical detail provides valuable data to generate hypotheses about causation with potential for future study to improve patient safety.

LEVEL OF EVIDENCE

Level III, therapeutic study.

A survey of international antisepsis procedures for neuraxial catheterisation in labour

BACKGROUND

Neuraxial analgesia during labour is a mainstay of anaesthetic practice globally. Despite the potential for significant neurological and infectious complications, international antisepsis practices for neuraxial anaesthesia vary widely.

AIMS

The primary aim of this study was to clarify international antisepsis practices prior to neuraxial analgesia in labour. The secondary aim was to determine an approximate international incidence of neuraxial infections and neurological complications secondary to neuraxial analgesia techniques in labour.

MATERIALS AND METHODS

Heads of Departments of Anaesthesiology were invited to complete an online questionnaire exploring antisepsis practices and complications of neuraxial catheterisation. Data from 151 institutions in 13 countries were collected over 11months.

RESULTS

Data were collected for an estimated 6008540 deliveries and 3770800 neuraxial catheterisations. The average annual birth rate per institution was 3979 births, with an average of 2497 neuraxial catheterizations (representing 62.8% of deliveries). Forty-nine percent of responders reported always wearing sterile gowns for the procedure, whereas 47.7% never wear gowns. Chlorhexidine was used by 88.1% of those surveyed, and 96.7% always wore facemasks. Thirty-four percent of institutions reported infectious complications over a 10-year period. Ninety neuraxial infections were estimated, giving an approximate incidence of 1:41898 catheterisations (2.39 infections per 100000 catheterisations). A total of 202 neurological complications were reported, with an approximate incidence of 1:18667 catheterisations (5.36 neurological complications per 100000 catheterisations).

CONCLUSION

The survey demonstrated marked variation in aseptic practice between both responding centres and countries. The incidence of infectious and neurological complications secondary to neuraxial catherisation in labour has been approximated.

Success with neurotropin in treating pediatric lower extremity pain induced by spinal cord injury after epidural anesthesia

Spinal cord injury (SCI) complicated by epidural anesthesia, though rare, can result in neuropathic pain. However, the treatment for this kind of life-altering injury remains a challenge. A 7-year-old girl was referred with dyskinesia and severe pain in her right lower extremity due to an accidental SCI following lumbar puncture. After treatment with analgesics such as gabapentin, mecobalamin, and dexamethasone/methylprednisolone for 1 week, the myodynamia had improved, but progressive pain persisted. After treatment with neurotropin, a gradual decrease in visual analog scale score from 7 to 0 was observed. We herein first describe that neurotropin produced sustained relief of pain induced by SCI. This case suggests that neurotropin might be a promising drug in treating pediatric neuropathic pain caused by SCI.

Safety Aspects of Postanesthesia Care Unit Discharge without Motor Function Assessment after Spinal Anesthesia

Background

Postanesthesia care unit (PACU) discharge without observation of lower limb motor function after spinal anesthesia has been suggested to significantly reduce PACU stay and enhance resource optimization and early rehabilitation but without enough data to allow clinical recommendations.

Methods

A multicenter, semiblinded, noninferiority randomized controlled trial of discharge from the PACU with or without assessment of lower limb motor function after elective total hip or knee arthroplasty under spinal anesthesia was undertaken. The primary outcome was frequency of a successful fast-track course (length of stay 4 days or less and no 30-day readmission). Noninferiority would be declared if the odds ratio (OR) for a successful fast-track course was no worse for those patients receiving no motor function assessment versus those patients receiving motor function assessment by OR = 0.68.

Results

A total of 1,359 patients (98.8% follow-up) were available for analysis (93% American Society of Anesthesiologists class 1 to 2). The primary outcome occurred in 92.2% and 92.0%, corresponding to no motor function assessment being noninferior to motor function assessment with OR 0.97 (95% CI, 0.70 to 1.35). Adverse events in the ward during the first 24 h occurred in 5.8% versus 7.4% with or without motor function assessment, respectively (OR, 0.77; 95% CI, 0.5 to 1.19, P = 0.24).

Conclusions

PACU discharge without assessment of lower limb motor function after spinal anesthesia for total hip or knee arthroplasty was noninferior to motor function assessment in achieving length of stay 4 days or less or 30-day readmissions. Because a nonsignificant tendency toward increased adverse events during the first 24 h in the ward was discovered, further safety data are needed in patients without assessment of lower limb motor function before PACU discharge.

Neuraxial blocks and spinal haematoma: Review of 166 case reports published 1994–2015. Part 1: Demographics and risk-factors

Background

Bleeding into the vertebral canal causing a spinal haematoma (SH) is a rare but serious complication to central neuraxial blocks (CNB). Of all serious complications to CNBs such as meningitis, abscess, cardiovascular collapse, and nerve injury, neurological injury associated with SH has the worst prognosis for permanent harm. Around the turn of the millennium, the first guidelines were published that aimed to reduce the risk of this complication. These guidelines are based on known risk factors for SH, rather than evidence from randomised, controlled trials (RCTs). RCTs, and therefore meta-analysis of RCTs, are not appropriate for identifying rare events. Analysing published case reports of rare complications may at least reveal risk factors and can thereby improve management of CNBs. The aims of the present review were to analyse case reports of SH after CNBs published between 1994 and 2015, and compare these with previous reviews of case reports.

Methods

MEDLINE and EMBASE were used for identifying case reports published in English, German, or Scandinavian languages, using appropriate search terms. Reference lists were also scrutinised for case reports. Twenty different variables from each case were specifically searched for and filled out on an Excel spreadsheet, and incidences were calculated using the number of informative reports as denominator for each variable.

Results

Altogether 166 case reports on spinal haematoma after CNB published during the years between 1994 and 2015 were collected. The annual number of case reports published during this period almost trebled compared with the two preceding decades. This trend continued even after the first guidelines on safe practice of CNBs appeared around year 2000, although more cases complied with such guidelines during the second half of the observation period (2005–2015) than during the first half. Three types of risk factors dominated:(1)Patient-related risk factors such as haemostatic and spinal disorders, (2) CNB-procedure-related risks such as complicated block, (3) Drug-related risks, i.e. medication with antihaemostatic drugs.

Conclusions and implications

The annual number of published cases of spinal haematoma after central neuraxial blocks increased during the last two decades (1994–2015) compared to previous decades. Case reports on elderly women account for this increase.Antihaemostatic drugs, heparins in particular, are still major risk factors for developing post-CNB spinal bleedings. Other risk factors are haemostatic and spinal disorders and complicated blocks, especially “bloody taps”, whereas multiple attempts do not seem to increase the risk of bleeding. In a large number of cases, no risk factor was reported. Guidelines issued around the turn of the century do not seem to have affected the number of published reports. In most cases, guidelines were followed, especially during the second half of the study period. Thus, although guidelines reduce the risk of a post-CNB spinal haematoma, and should be strictly adhered to in every single case, they are no guarantee against such bleedings to occur.

Spinal Cord Infarction in the Course of a Septic Shock: About One Case and Review of the Literature

We report the case of a patient admitted to our intensive care unit in the course of a septic shock, secondary to cholangitis. After rapid hemodynamic stabilization, antibiotherapy, and endoscopic extraction of bile ducts stones, she appeared to have developed flaccid paraplegia. The suspected diagnosis of medullar ischemia was confirmed by typical MRI findings. This case stresses the potential pathogenic role of hypotension in medullar ischemia and the place of magnetic resonance imaging (MRI) as a reliable diagnostic tool.

Spinal subarachnoid haematoma after spinal anaesthesia: case report

Subarachnoid haematoma after spinal anaesthesia is known to be very rare. In the majority of these cases, spinal anaesthesia was difficult to perform and/or unsuccessful; other risk factors included antiplatelet or anticoagulation therapy, and direct spinal cord trauma. We report a case of subarachnoid haematoma after spinal anaesthesia in a young patient without risk factors.

[Spinal subarachnoid haematoma after spinal anaesthesia: case report]

Subarachnoid haematoma after spinal anaesthesia is known to be very rare. In the majority of these cases, spinal anaesthesia was difficult to perform and/or unsuccessful; other risk factors included antiplatelet or anticoagulation therapy, and direct spinal cord trauma. We report a case of subarachnoid haematoma after spinal anaesthesia in a young patient without risk factors.

Use of direct oral anticoagulants with regional anesthesia in orthopedic patients

The use of direct oral anticoagulants including apixaban, rivaroxaban, and dabigatran, which are approved for several therapeutic indications, can simplify perioperative and postoperative management of anticoagulation. Utilization of regional neuraxial anesthesia in patients receiving anticoagulants carries a relatively small risk of hematoma, the serious complications of which must be acknowledged. Given the extensive use of regional anesthesia in surgery and the increasing number of patients receiving direct oral anticoagulants, it is crucial to understand the current clinical data on the risk of hemorrhagic complications in this setting, particularly for anesthesiologists. We discuss current data, guideline recommendations, and best practice advice on effective management of the direct oral anticoagulants and regional anesthesia, including in specific clinical situations, such as patients undergoing major orthopedic surgery at high risk of a thromboembolic event, or patients with renal impairment at an increased risk of bleeding.