Complications of obstetric anesthesia,Apice course 2001.

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Complications in ob anesthesia,especiallly neurological complications.

Complications in ob anesthesia,especiallly neurological complications.

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  • 1. Complications in obstetric anesthesia Complications in obstetric anesthesia C.MelloniC.Melloni Servizio di Anestesia e RianimazioneServizio di Anestesia e Rianimazione Ospedale di Faenza(RA)Ospedale di Faenza(RA)
  • 2. Report on Confidential enquiries into maternal deaths in England and Wales 1970-1996 0 5 10 15 20 25 30 1970-72 73-75 76-78 79-81 82-84 85-87 88-90 91-93 94-96 Entrata in vigore della nuova
  • 3. Maternal deaths attributed to anesthesia 0 2 4 6 8 10 12 14 1970- 72 73-75 76-78 79-81 82-84 85-87 88-90 91-93 94-96
  • 4. Maternal deaths related to anesthesia per million of pregnancies estimated for England & Wales 0 5 10 15 20 25 30 35 40 70- 72 73- 75 76- 78 79- 81 82- 84 85- 87 88- 90 91- 93 94- 96 deaths direct assoc. freq.per million % direct deaths
  • 5. Pattern of maternal deaths US.assoc.with anesthesiaPattern of maternal deaths US.assoc.with anesthesia NY 1979-81;Indiana 60-80NY 1979-81;Indiana 60-80 IndianaIndiana Aspir of gastric content Aspir of gastric content cardioreso arrest cardioreso arrest N.YN.Y 12 GA12 GA Aspir of gastric content Aspir of gastric content cardioreso arst cardioreso arst cardiac arrest cardiac arrest 1 RA(bupi i.v .) 1 RA(bupi i.v .)
  • 6. Patterns of maternal mortality associated with anesthesia Patterns of maternal mortality associated with anesthesia Enngland & WalesEnngland & Wales 1970-781970-78 68 from GA:40 aspiration,28 oti problems68 from GA:40 aspiration,28 oti problems 1985-871985-87 7 from GA:5 error in OTI;1 aspiration,1 kinked ETT 7 from GA:5 error in OTI;1 aspiration,1 kinked ETT 1 from reg;cardiovasc collpase under epidural block in a patient with aortic insuff. 1 from reg;cardiovasc collpase under epidural block in a patient with aortic insuff.
  • 7. Incidence of failed iot • Hawthorne, L.; Wilson, R.; Lyons, G.; Dresner, M. Failed intubation revisited: 17- yr experience in a teaching maternity unit • Br. J. Anaesth. 1996; 76:680-684. • 16 years at St James • 5802 GA * C/S • 0.4% failed IOT;1/300 1984,1/250 1994.
  • 8. Failed IOT frequency(Tsen et al,Int J.Obset Anesth. 1998;7:147) 0 2 4 6 8 10 12 14 16 1990 1991 1992 1993 1994 1995 iot fallite
  • 9. Mallampati Score changes during pregnancy (Piklington et al,BJA 1995;74:638) 0 10 20 30 40 50 60 % 1 2 3 4 12-set 38 sett score
  • 10. Difficult OTI increase in obstetrics 0 0,2 0,4 0,6 0,8 1 1,2 1,4 1,6 1,8 % score 3 chir gen C/S (Pilk) C/S (Durban) ost (Carli)
  • 11. Difficult OTI etiology • Anatomical variations • Organizational factors: – inexperience – Extra hours emerg. – “stat” mentality – panic 0 10 20 30 40 50 60 70 80 90 % elettive emergenza Iot fallite e tipo di C/S(Hawthorn,BJA 1996 % AG fallite
  • 12. Unnecessary GA • Inadequate patient education • Surgeons habits • Late call • Surpassed indications: – preeclampsia – placenta praevia – fever – Cardiac disease
  • 13. Difficult intubation cart: • In OR: • Choice of laryngoscopes:handles and blades • Guedel,Copa • LMA ,:Proseal… • Combitube • ventlating bougies,hockey club… • Crico- thiroidotomy set:Patil,Ravussin,ecc • FBS. • jet ventilation……...
  • 14. Risk factors evaluation • Anretenatal visit • 90% of urgent C/S can be prevented (risk factors…) • Pre..emptive pd. To avoid GA.(Morgan et al.Anesthesia for emergency cesarean section.Br.J Obstet.Gynecol. 1990;97:420-24). • Large study pf outpatient obstetric anesthesia clinic:(Hamza et al.Anesthesia consultaion can decrease the need for general anesthesia for emergency cesarean section in parturients with difficult airway.Br.J.Anesth 1995;74:A353.):10%present at least 1 Risk factor for difficult OTI
  • 15. Hawkins JL,Koonin LM,Palmer SK,Gibbs CP.Anesthesia related deaths during obstetric delivery in the United States(Anesthesiology 1997;86:277-84). • Maternal deaths reported in USA 1979- 1990 • cause • relation to anesthetic • type of obstetric procedure • associated maternal conditions.
  • 16. Estimates from CDC USAEstimates from CDC USA 1979-841979-84 Cs 19%Cs 19% GA 41%,REG 55%GA 41%,REG 55% 1990-921990-92 CS 24%CS 24% GA 16%,REG 84%GA 16%,REG 84% MortalityMortality 82% from CS82% from CS
  • 17. Hawkins JL,Koonin LM,Palmer SK,Gibbs CP.Anesthesia related deaths during obstetric delivery in the United States(Anesthesiology 1997;86:277-84). 0 2 4 6 8 10 12 14 16 18 % 79-81 82-84 85-87 88-90 num.tot=129 GA REG unknown sedation
  • 18. Maternal mortality and anesthesia • 4.3/milion live births ( 1979—1981) • 1.7/ milion live births (1988—1990). • 8.7/ milion live births( 1979—1981) • 1.7/ milion live births (1988—1990). CDC USA CEMDEW
  • 19. From CDC USA fatalities :GA vs reg. • GA 2.3 > reg (1979—1984) • GA 16.7 > reg ( 1985—1990).
  • 20. Complication rate AG * C/S: CDC USA • Deaths: • 20.0/million GA ( 1979—1984) • 32.3 /million (1985—1990)
  • 21. Mortality ( CS )in Reg anest CDC USA • 8.6 /million of Reg anest.( 1979—1984) • 1.9 /million ( 1985—1990).
  • 22. Chadwick,HS,Posner,K,Kaplan,RA,Ward,RJ,Ch eney FW.A comparison of obstetric and nonobstetric anesthesia malpractice claims.Anesthesiology 1991;74:242-249. • ASA closed claims project • Malpractice claims against anesthesiologists • ob vs non ob:190 vs 1351 – ob cases :67% CS,33% vaginal – 65% assoc with Reg anest,;33% with GA – 2 claims * anesth not available!
  • 23. Damaging events in obs vs nonobs claims 0 2 4 6 8 10 12 14 % ob nonob inadeq.ventilation difficult intub pulm.aspir. esoph.intub bronchospasm inadeq.FiO2 airways obstruct. estubaz prematura convuls equipment problems drug mistake fluid mistake blood loss trans.mistake * * * Probl.resp Probl cardiocirc
  • 24. Maternal damage:CS vs vaginal delivery 0 5 10 15 20 25 % CS vag maternal death neonatal cerebral damage headache neonatal death pain during anesth. neural damage cerebral damage pt) emotional distress dorsalgia *
  • 25. Obstetrical claims;reg vs ga 0 5 10 15 20 25 30 35 40 45 % reg GA maternal death neonatal cerebral damage headache neonatal death pain during anesth. neural damage cerebral damage pt) emotional distress dorsalgia * * * *
  • 26. Neonatal damageNeonatal damage pathogenesispathogenesis 45% :anesthesia related45% :anesthesia related 4 GA :1 bronchospasm,1 oesophag.intub,1 pulm.aspir,1 anesth,delay; polm,1 anesth delay) , 13 reg:,9 convulsafter intravasc adm;1 eclampsia,1 medical delay,3 high spinal 4 GA :1 bronchospasm,1 oesophag.intub,1 pulm.aspir,1 anesth,delay; polm,1 anesth delay) , 13 reg:,9 convulsafter intravasc adm;1 eclampsia,1 medical delay,3 high spinal 37% : obstetrical or congenital problems37% : obstetrical or congenital problems 13% resuscitation problems13% resuscitation problems
  • 27. Pulmonary inhalationPulmonary inhalation 8% ob claims vs 2% non ob claims8% ob claims vs 2% non ob claims 50% associated with difficult intub;oesophageal or inadequate ventilation 50% associated with difficult intub;oesophageal or inadequate ventilation 14/16 associated with GA14/16 associated with GA 7 cases of mask anesth & 6 cases of oesophageal intub.or difficult intubation7 cases of mask anesth & 6 cases of oesophageal intub.or difficult intubation 2 cases associated with reg anesth2 cases associated with reg anesth Tetrac 20 mg and 4 administered by the obs-resp insuff-ETT after 6-7 min by anesth--hypoxia Tetrac 20 mg and 4 administered by the obs-resp insuff-ETT after 6-7 min by anesth--hypoxia
  • 28. ConvulsionsConvulsions 10% in ob claims vs 1% non ob claims10% in ob claims vs 1% non ob claims 83% associated with severe neurological damage ,maternal and/or neonatal death 83% associated with severe neurological damage ,maternal and/or neonatal death 18/19 during epid.anest.18/19 during epid.anest. 10/17 no test dose w.adr10/17 no test dose w.adr 15/17 bupi…15/17 bupi… 2/19 eclampsia2/19 eclampsia
  • 29. Equipment problemsEquipment problems 5/11 :epid cath.teared5/11 :epid cath.teared non functioning defibnon functioning defib 5 ventilator problems5 ventilator problems exp side connected to the ventilatorexp side connected to the ventilator circuitry errorcircuitry error N2 in circuitN2 in circuit
  • 30. Damage severity classification Temporary: 0:not obvious 1: emotional fear,pain… 2:not signif:;lacer,contus,no recovery retardation 3:minor.eg.g.fall,recovery retard. 4:major;cerebral damage,neurologic,recovery retard. • Permanent ∨ 5:minor:organ damage,not debil.; ∨ 6:significant;e.g.eye or kidney loss, 7:major;paraplegia,blindness ,cerebral damage ∨ 8:severe:;severe cerebral damage,quadriplegia, life care ∨ 9:death.
  • 31. Severity Injury Score (SIS) • Ob: SIS median 3 vs non ob ,median 7 • Max SIS equal • But different distribution………. • Median + after GA; maternal death 47% of claims in AG vs 12% after reg. 0 5 10 15 20 25 30 35 40 % minore(0-3) magg(4-6) invalidità(7- 8) morte(9) ob non ob
  • 32. Payment data in $ reg gen not paid(%) 32 38 43 27 paid (%) 59 53 48 63 median payment 85000 203000 91000 225000 payment angerange 15000-6mil 675000-5.4 mil 675-2.5 mil750-5.4 mil GA paid 63% vs 48% reg.
  • 33. Conclusions from the closed claims:1Conclusions from the closed claims:1 cerebral neonatal damagecerebral neonatal damage 50% not anesth.related50% not anesth.related median payment:500.000$ vs 120.000 for other ob.claims median payment:500.000$ vs 120.000 for other ob.claims
  • 34. Conclusions from the closed claims Conclusions from the closed claims HeadacheHeadache 3rd complaint3rd complaint payment in 56%payment in 56%
  • 35. Maternal sequelae post partum:from Crawford 1978-85. • Birmingham,UK,11701 questionn. in 30096 deliveries: • dorsalgia 14% • headache 4% • Parestesth.:hands 2.5%,lower limbs 0,2 % (Reg anest) • Bladder stress incontinence 15%,disuria 4% (prolonged labors,forceps..)
  • 36. Scott DB, Hibbard BM. Serious non-fatal complications associated with extradural block in obstetric practice. Scott DB, Hibbard BM. Serious non-fatal complications associated with extradural block in obstetric practice. British Journal of Anaesthesia 1990; 64:537-541.British Journal of Anaesthesia 1990; 64:537-541. 505.000 extradural blocks:i,84% labour; 16% C/S ( 203 units,,1982-86, 2.580.000 deliveries: 505.000 extradural blocks:i,84% labour; 16% C/S ( 203 units,,1982-86, 2.580.000 deliveries: 108 events;5 permanent sequelae108 events;5 permanent sequelae 60 acute reactions60 acute reactions
  • 37. Scott DB, Hibbard BM. Serious non-fatal complications associated with extradural block in obstetric practice. Scott DB, Hibbard BM. Serious non-fatal complications associated with extradural block in obstetric practice. 5 cranial nn palsies5 cranial nn palsies 1 subd hematoma(accid.dural punct)1 subd hematoma(accid.dural punct) 38 periph.neuropathies(single nerve)38 periph.neuropathies(single nerve) 1 quadriplegia (thrombosis of cervical haemangioma)1 quadriplegia (thrombosis of cervical haemangioma) 1 paraplegia1 paraplegia 1 abscess & 1 subdural hematoma (evacuated with success) 1 abscess & 1 subdural hematoma (evacuated with success)
  • 38. Scott DB, Tunstall ME. Serious complications associated with epidural/spinal blockade in obstetrics. Scott DB, Tunstall ME. Serious complications associated with epidural/spinal blockade in obstetrics. International Journal of Obstetric Anesthesia 1995; 4:131-137. eadingsInternational Journal of Obstetric Anesthesia 1995; 4:131-137. eadings obs anesthesiologists surveyobs anesthesiologists survey 123000 blocks/216816 deliveries123000 blocks/216816 deliveries 46 isolated neuropathies of a single spinal nerve46 isolated neuropathies of a single spinal nerve 8 cases of prolonged urinary retention8 cases of prolonged urinary retention
  • 39. Holdcroft A, Gibberd FB, Hargrove RL, Hawkins DF, Dellaportas CI. Neurological complications associated with pregnancy. British Journal of Anaesthesia 1995; 75:522-526. Holdcroft A, Gibberd FB, Hargrove RL, Hawkins DF, Dellaportas CI. Neurological complications associated with pregnancy. British Journal of Anaesthesia 1995; 75:522-526. all 48066 deliv of North West Thames in 1 year:19 neurological disturbancesall 48066 deliv of North West Thames in 1 year:19 neurological disturbances 2 hypoxic cerebr.damage2 hypoxic cerebr.damage 1 post cardiac arrest(myopathia):exitus1 post cardiac arrest(myopathia):exitus 1 following haemorrhage :residual tetraparesis1 following haemorrhage :residual tetraparesis 5 neural root damage5 neural root damage Bell,cervical,L5 disc prolapse,preexisting sciatica,foot drop(spontaneous delivery under nitrous oxide analgesia of a large baby via a small pelvis) Bell,cervical,L5 disc prolapse,preexisting sciatica,foot drop(spontaneous delivery under nitrous oxide analgesia of a large baby via a small pelvis)
  • 40. Holdcroft et al. Neurological complications associated with pregnancy. British Journal of Anaesthesia 1995; 75:522-526. Holdcroft et al. Neurological complications associated with pregnancy. British Journal of Anaesthesia 1995; 75:522-526. 3 periph.nn.paralysis:lat.pop.,ulnar,meralgia parestetica3 periph.nn.paralysis:lat.pop.,ulnar,meralgia parestetica 5 medical concauses5 medical concauses 2 from space occup.lesions,1 mult.scler.,1 diabetic ,1 meningitis 2 from space occup.lesions,1 mult.scler.,1 diabetic ,1 meningitis 2 dorsal pain2 dorsal pain 1 paresth.of a neural root dstrib.1 paresth.of a neural root dstrib.
  • 41. Neurological complications associated with Reg anesth Neurological complications associated with Reg anesth 78 cases in Medline within 1998:Lee CC.Int J Obstet.Anest78 cases in Medline within 1998:Lee CC.Int J Obstet.Anest epid.abscessepid.abscess meningitismeningitis aseptic meningitisaseptic meningitis aracnoiditisaracnoiditis spinal hematomaspinal hematoma subdural cranial hematomasubdural cranial hematoma ant spinalis art.syndromeant spinalis art.syndrome cranial nn.palsiescranial nn.palsies direct trauma(catheter,needle...)direct trauma(catheter,needle...)
  • 42. Why do we have problems with obstetric analgesia Why do we have problems with obstetric analgesia joy/damagejoy/damage anesthesiologist visibility anesthesiologist visibility obstetricians "scaricabarile" obstetricians "scaricabarile" invisibility the fetal head invisibility the fetal head preference for regional anesthesia preference for regional anesthesia
  • 43. Eziologia del danno neurologico in ostetricia • Cause mediche intercorrenti; – ascesso o ematoma epidurale spontaneo – esacerbazione di: • malattie del collagene • patologie vascolari • polineuropatie • neuriti postinfettive • sclerosi multipla • discesa del feto nella pelvi: – compressione del tronco lombosacrale; • nn.sciatico,femorale,otturatorio,lat.cutaneo,peroneo comune……..
  • 44. Etiology of neurological sequelaeEtiology of neurological sequelae unrelated to regional anesthesiaunrelated to regional anesthesia surgical position,delivery positionsurgical position,delivery position surgical trauma(forceps)surgical trauma(forceps) (cast and dressing application)(cast and dressing application) compression by tourniquet,stirrups,fetal head ....compression by tourniquet,stirrups,fetal head .... undiagnosed neurological disease:spont epid.abscess or hematomaundiagnosed neurological disease:spont epid.abscess or hematoma exacerbation of collagen dis.,vascular,polyneuropathy,mult sclerosis,postinfectious neuritis.... exacerbation of collagen dis.,vascular,polyneuropathy,mult sclerosis,postinfectious neuritis....
  • 45. Etiology of neurological complicationsEtiology of neurological complications related to reg.anesthrelated to reg.anesth neurotoxicityneurotoxicity direct neural tissue injurydirect neural tissue injury spinal hematomaspinal hematoma spinal abscessspinal abscess meningitismeningitis ischemiaischemia reg.anesth.per sereg.anesth.per se direct trauma by needle,catheter,injection...direct trauma by needle,catheter,injection...
  • 46. Incidence of motor defict following epidural anesthesia • Author cases incid /10.000 • Dawkins 32718 14.7/2.1(trans/perm) • Crawford 2035 0 • Aboulesih 1417 14.1 • Bonica 3637 2.7 • Lund 10000 1 • Hellman 26127 0 • Moore 6729 0 • Bleyaert 3000 0 • Ong 9403 0.8
  • 47. Neurological complications of regional anesthesia in obstetrics • Kandel (1965);0 / 1000 • Crawford(1972);0 / 1035 • Holdcroft(1976);1 7 1000 • Bleyaert(1979);0 / 3000 • Abouleish(1981);3 / 1417 • Crawfoed(1985);4 / 27000 • Ong(1987);34 / 9403 • Scott(1990);43 / 505000 • Scott(1995):38 / 108133 • Holdcroft(1995);1 / 13007 • Puech(1999);1 / 10995
  • 48. Maternal injury files(Chadwick) • 356 cases: n. % • maternal death: 83 23 • headache 64 18 • nerve/spinal cord trauma 41 12 • pain anesth 37 10 • back pain 34 10 • brain damage 32 9 • emotional distress 31 9 • aspiration pneumonitis 20 6
  • 49. NeurotoxicityNeurotoxicity ChloroprocaineChloroprocaine 5% lidocaine5% lidocaine TRI....TRI....
  • 50. TRITRI uneventful single shot spinal anesthesiauneventful single shot spinal anesthesia low back painlow back pain dysesthesiasdysesthesias radiation to the thighradiation to the thigh hyperbaric 5% lidocainehyperbaric 5% lidocaine
  • 51. cauda equina syndromecauda equina syndrome tox.of LA spinal anesthetics?tox.of LA spinal anesthetics? paraparesis,paraplegia,numbness in the saddle area,incompretence of bladder and anal sphincter paraparesis,paraplegia,numbness in the saddle area,incompretence of bladder and anal sphincter permanent deficitspermanent deficits
  • 52. High subarachnoid blockHigh subarachnoid block high spinal dosehigh spinal dose continuous spinalcontinuous spinal inadvertent spinal from epidural.inadvertent spinal from epidural. repeated injections after failed spinal..repeated injections after failed spinal.. Top ups :attention!Top ups :attention!
  • 53. Incidence of paresthesias following epidural anesthesia • Author cases incid /10.000 • Crawford 2035 14.7 • Eisen 9532 16.8 • Abouleish 1417 42.3 • Lund 10000 5 • Bonica 3637 24.7 • ONG 9403 36.2
  • 54. Ong BY,Cohen MM,Esmail A,Cumming M,Kozody R,Palahniuk RJ.Paresthesias and motor dysfunction after labor and delivery.AA,1987;66:18-22. • Winnipeg Women Hospital,1975-83,23827 deliveries • analg/anesth applied: – none 8198 – inhalatory analg. 4766 – epid.analg 9403 – GA 864 – other 381 – not codif 215 – delivery: • spont. vag. 53.4% • forceps//vacuum 27.9% • C/S 18.6%
  • 55. Paresthesias and motor dysfunction after labor and delivery Incidence of paresthesias& motor dysfunction:18.9/10.000(45 cases) 0 5 10 15 20 25 30 35 40 /10.000 multipar primipar vag spont forceps,vacuum no analg analg. Inalat epid only GA * * * *
  • 56. Other problems associated with anesth/analg: • PDPH • Assoc with cranial subdural hematoma:8 cases <1990 Medline • assoc with cranial nn.palsies;diplopia,tinitus,vertigo…….. • Long term dorsalgia………...
  • 57. Accidental dural puncture rates(Cowan IJOA 2001;10:1-16) • Incidence:0.25-0.5% • reduced dural puncture;frequence • experience • non rotation of the needle • choice of technique:lateral decubitus+loss of resist with saline+non rotation of needle
  • 58. Dural puncture ko • Pdph.80% FOLLOWING LARGE NEEDLES • cranial nerve palsy;1-3.7%:abducens vestibulocochlear…:gen benign,rare,may take months to resolve • cranial subdural haematoma;1/500.000(Scott 1990)
  • 59. • Any persistent postspinal headache or recurrence of it should alert the anesthesiologist……… » LOO IJOA 2000
  • 60. PDPH DD • Headaches: • Migraine • fatigue, • anxiety, • post partun blues, • pp depression • preexistent headache, • Musc. contraction • depress.equiv and conversion reaction • Cluster • Analgersics abuse(Olesen BMJ 1995)
  • 61. Long term morbidity following dural puncture(Jeskin IJOA 2001;10:17-24.) • Case controled retrospective mail survey • 194 mother with accidental dural pun. • Low response rate • 18% long term headache(3.6 years) • following spinal anesth 0.89% > 1 year
  • 62. Petroclinoid ligament
  • 63. Peripartum paralysis • Trauma :.peripheral/central • vascular:epidural hematoma,spinal cord ischemia,anterior spinal artery syndrome – chemical;neurotoxicity – infection:epidural abscess,meningitis,tbc,HIV – congenital;syringomielia,spinal cyst,AVM – new growths;tumor – degeneration:herniated disc,spinal stenosis,Paget..
  • 64. Etiology of paralysisEtiology of paralysis coexisting disease coexisting disease iatrogeniciatrogenic intraspinal sepsis intraspinal sepsis parturition process parturition process visibility of reg anesth....visibility of reg anesth....
  • 65. Visibility of reg anesth…..
  • 66. Nerve traumaNerve trauma Auroy,Y.Anesthesiology 97;87:479-86 &Auroy,Y.Anesthesiology 97;87:479-86 & Scott IJOA 95;4:133-9.Scott IJOA 95;4:133-9. NumberNumber 24/40640 & 38/505.00024/40640 & 38/505.000 clinical presentationclinical presentation paresthesia during puncture or pain during injectionparesthesia during puncture or pain during injection resulting radiculopathyresulting radiculopathy same topgraphy as the associated paresth.same topgraphy as the associated paresth. prognosisprognosis reversible <15gg (3 mon);2 cases persistentreversible <15gg (3 mon);2 cases persistent
  • 67. Foetal head descent
  • 68. Maternal obstetric palsiesMaternal obstetric palsies Bademosi,Int J Obstet.Gynecol 1980;17:611-614Bademosi,Int J Obstet.Gynecol 1980;17:611-614 Plexus injury 85%(29 cases)Plexus injury 85%(29 cases) Spinal cord injury 15%(5 cases)Spinal cord injury 15%(5 cases)
  • 69. Paresthesia and nerve damage following CSE & spinal(Holloway et al IjOA 2000;9:151-55) 0 10 20 30 40 50 60 non surg surgical uncertain all CSE SSS all
  • 70. Damage to the conus medullaris following spinal anesthesia Damage to the conus medullaris following spinal anesthesia Reynolds,F.Anaesthesia 2001;56:238-47Reynolds,F.Anaesthesia 2001;56:238-47 6 cases6 cases pain on insertion alwayspain on insertion always Syrinx at MRI:always coincident with neurologySyrinx at MRI:always coincident with neurology urinary problems:50%urinary problems:50% sensory problems unilat;L4 /L5-s1-s3sensory problems unilat;L4 /L5-s1-s3 motor impairment:foot dropmotor impairment:foot drop
  • 71. Position of the tip of the conus medullaris as referred to the adjacent third of the vertebral body or disc space. Position of the tip of the conus medullaris as referred to the adjacent third of the vertebral body or disc space. frequency distribution for conus levelfrequency distribution for conus level countcount %% T12M3T12M3 99 1,791,79 T12L3T12L3 2020 3,973,97 T12/L1T12/L1 3333 6,556,55 L1U3L1U3 5757 11,3111,31 L1M3L1M3 6868 13,6913,69 L1I3L1I3 127127 25,225,2 L1/L2L1/L2 8282 16,2716,27 L2U3L2U3 6060 11,911,9 L2M3L2M3 2727 5,365,36 L2I3L2I3 1414 2,782,78 L2/L3L2/L3 55 0,990,99 L3U3L3U3 11 0,20,2
  • 72. The level of PL was falsely evaluated in 62% of cases.puncture performed 1-2 interspaces higher than assumed…(Van Gassel 1993)
  • 73. Broadbent et al Anesthesia 2000 T12- L1 L1- L2 L2- L3 L3- L4 L4- L5 L5- S1 S1- S2 T11 - T12 2 3 1 T12 -L1 10 4 2 L1- L2 1 16 39 24 L2- L3 5 26 45 L3- L4 13 5 L4- L5 2 L5-S1 1 1 Actual level Anesthesiologist opinion
  • 74. Inability to identify correctly the intervertebral spaces Inability to identify correctly the intervertebral spaces "provare per credere""provare per credere" Correct identificationCorrect identification only 29% of casesonly 29% of cases actual interspaceactual interspace 1-4 interspaces higher than assumed in 68% of cases 1-4 interspaces higher than assumed in 68% of cases it cannot be recommended to insert the spinal needle higher than L3-L4 at the highest. it cannot be recommended to insert the spinal needle higher than L3-L4 at the highest. Reynolds Anesthesia 2000 Reynolds Anesthesia 2000
  • 75. In pregnant patients at term cephalic pelvic tilt may further displace the apparent intercristal line in a cephalad direction...:
  • 76. Risk of epidural abscessRisk of epidural abscess laborlabor 1/500.000(Scott)--1/27.000 Crawford1/500.000(Scott)--1/27.000 Crawford epid anesth.epid anesth. 1/75.000(Acta Anesth.Scand 1987-95)1/75.000(Acta Anesth.Scand 1987-95) 45 cases in Medline(Schneidr,com WCA 2000) 45 cases in Medline(Schneidr,com WCA 2000)
  • 77. Epidural abscessEpidural abscess SpontaneousSpontaneous 5 cases;5 cases; haematogenous spread from vaginahaematogenous spread from vagina Staph aureus/Gr B streptococcusStaph aureus/Gr B streptococcus associated with peridural anesth.associated with peridural anesth. incidence:0.2-3.7/100.000incidence:0.2-3.7/100.000 staph aureus(bact typing)staph aureus(bact typing) risk incr with the catetherization length.risk incr with the catetherization length. Loo 2000 JIOA;9:99-104.Loo 2000 JIOA;9:99-104.
  • 78. Epidural abscessEpidural abscess Clinical featuresClinical features spinalachespinalache nerve root painnerve root pain weaknessweakness paralysisparalysis feverfever WBC+WBC+ reflexes alterationreflexes alteration neck stiffnessneck stiffness headacheheadache aggressive surgical treatmentaggressive surgical treatment Aggressive surgical managem ent(drainage??? Aggressive surgical management(drainage??? Blood cult(25 MRI gadol en
  • 79. MeningitisMeningitis bacterialbacterial associated with RAassociated with RA Streptococcus 40%,pseud aer 20%,sraph epidermid 7%Streptococcus 40%,pseud aer 20%,sraph epidermid 7% spontaneousspontaneous Strept pneum,N.mening.,Haem infl.Strept pneum,N.mening.,Haem infl. SPI>>epidSPI>>epid Loo 2000 IJOA,;9:99-104. & Scheenberger Infection 96;24:29-35.Loo 2000 IJOA,;9:99-104. & Scheenberger Infection 96;24:29-35. >'83 shift from Gram neg to alpha haem.streptococ.>'83 shift from Gram neg to alpha haem.streptococ.
  • 80. MeningitisMeningitis incidence 3/65000 spi(Kane,1982);incidence 3/65000 spi(Kane,1982); 1/100.000 epid(Palot 1994)1/100.000 epid(Palot 1994) risk factors:risk factors: dural puncture?dural puncture? not wearing a face mask?not wearing a face mask? ????
  • 81. Prevention of epi/spinal infectionsPrevention of epi/spinal infections alwaysalways surg.prepsurg.prep filtersfilters do not leave catheters if not necessary----do not leave catheters if not necessary---- asepsis for every injectionasepsis for every injection
  • 82. Spinal epidural haematomaSpinal epidural haematoma reluctance to report......reluctance to report...... Scott-HibbardScott-Hibbard 0,0020,002 Hodlcroft,Paech,Scott,Tunstall(prospective)Hodlcroft,Paech,Scott,Tunstall(prospective) 182.000 blocks & no problem...182.000 blocks & no problem... Vandermeulen:11 surveysVandermeulen:11 surveys 258987 spi, 65304 epi..no problem258987 spi, 65304 epi..no problem
  • 83. Spinal haematoma in absence of coagulopathy or thromboprophylaxis Spinal haematoma in absence of coagulopathy or thromboprophylaxis extremely rareextremely rare risk factorsrisk factors difficult multiple punctures.difficult multiple punctures. bloody puncturesbloody punctures epid catheter insertionepid catheter insertion removal of an epid.catetherremoval of an epid.catether
  • 84. Risk of spinal / epidural haematomaRisk of spinal / epidural haematoma data form large surveys..data form large surveys.. labour:labour: epidural:1/500.000(scott 1990)epidural:1/500.000(scott 1990) spinal:0spinal:0 operativeoperative peridural;1:190.000(CI 1/4060000-1/97000)(Wolf-Tryba)peridural;1:190.000(CI 1/4060000-1/97000)(Wolf-Tryba) spinal :1/240000spinal :1/240000
  • 85. Guidelins for safe epidural (spinal) practice Guidelins for safe epidural (spinal) practice from H Breivik & Co.from H Breivik & Co. strict aseptic techniquestrict aseptic technique in case of prolonged epid.pain control maintain analgesia with minimal motor blockin case of prolonged epid.pain control maintain analgesia with minimal motor block daily monitoring of the catheter insertion sitedaily monitoring of the catheter insertion site continuous surveillance for any increasing leg weaknesscontinuous surveillance for any increasing leg weakness teaching programme for nurses and medical staffteaching programme for nurses and medical staff inform the patient of the significance of leg weaknessinform the patient of the significance of leg weakness high index of diagnostic suspicionhigh index of diagnostic suspicion high preparedness for rapid handlinghigh preparedness for rapid handling
  • 86. Conclusions from neurological complications attributed to labor and delivery • Not rare(estim.incid 1: 2530 • often accompanied by a prolonged and difficult labor • if assoc with regional anesth,again associated with a prolonged and difficult labor • :they do not constitute a risk factor per se • but…call for higher standards of practice
  • 87. Control & prevention • Standards of care • total quality management: – evaluation of individual risk/benefit – patient control – complications audit – training of the team rsponsible of peripartum are – information on possible complications