Complications during and after surgery and childbirth where spinal or epidural analgesia is used. Guidelines for safe practice

When complications and neurological sequelae occur during a spinal or epidural anaesthetic the causes are clearly related to the procedures in the following cases: severe haemodynamic or respiratory derangement, documented needle trauma of nerve fibres, intraspinal haematoma in anticoagulated or heparinized patients, and epidural infection where an infected epidural catheter entry site is documented. A number of well documented cases have been published in which surgery or patient-related pathology were primary causes of "typical" spinal or epidural neurological complications. These emphasize the importance of searching for other risk factors of neurological sequelae after surgery or child birth in cases where there is no obvious deviation from the normal epidural or spinal procedures. Increased focus on the infrequent, but serious complications of these essentially very safe techniques for surgical anaesthesia and pain relief should serve to increase our vigilance, but should not reduce the application of spinal and epidural analgesia. Guidelines are offered for the effective and safe practice of spinal and epidural anaesthesia and pain relief: adequate supervision of trainee anaesthetists, vigilant monitoring for early detection and handling of complications, and trained nurses on surgical wards to monitor and handle patients during epidural analgesia are important. Sufficient readiness for urgent handling of the very rare, but devastating complications of intraspinal bleeding or infection is an absolute necessity.     

Obstetric analgesia in Norwegian hospitals]

We report the results of a questionnaire sent to anaesthetists and midwives on the use of obstetric analgesia and anaesthesia in Norwegian hospitals in 1996. 95% of the 49 hospitals involved responded to the questionnaire, representing a total of 56,884 births. The use of epidural analgesia in labour varied from 0 to 25% in the different hospitals with a mean value of 15%. Epidural analgesia was much more widely used in university and regional hospitals than in local hospitals (p < 0.001). Five of the local hospitals did not offer epidural analgesia during labour at all. The combination of low-dose local anaesthetic and an opioid (either sufentanil or fentanyl) had not been introduced in nine of the hospitals (20%). The optimal use of epidural analgesia to relieve labour pain was judged to be more frequent by the anaesthetists than by the midwives (19% versus 11%, p < 0.01). In response to what factors limited the frequency of epidural analgesia, the anaesthetists specified factors related to the attitude of the midwife, and the midwives specified factors related to the anaesthetist. Only five of the hospitals provided written information on the various analgesic methods that could be employed during labour. The majority of midwives considered the analgesic methods employed on their maternity ward to be good or excellent. The frequency of Caesarean section was 12%; spinal anaesthesia was used in 55%, epidural anaesthesia in 17%, and general anaesthesia in 28% of the cases.     

Cytotoxic and ichthyotoxic compounds from marine Opisthobranchia and soft coral

Epidural analgesia in labour using local anaesthetics is very efficient, but the technique has been associated with undesired motor block and an increased use of instrumental deliveries. A new epidural analgesia technique, using a combination of low-dose local anaesthetics and opioids (fentanyl and sufentanil), has recently come into practice. The new epidural technique provides excellent analgesia, minimises motor block, allows the mother to ambulate, and minimises the need for instrumental delivery. Furthermore, it constitutes a good alternative to parenteral pethidine. We are of the opinion that all pregnant women should be given detailed information about both the benefits and the possible side-effects of epidural analgesia in good time before they go into labour. This will allow them to participate more actively in deciding whether or not to use analgesia during labour. Optimal use of epidural analgesia not only depends on the availability of a 24-hour anaesthesia service, but also on adequate knowledge and the cooperation and enthusiasm of all those involved, namely midwives, obstetricians and anaesthesiologists.     

Value of combined spinal and epidural anesthesia in the management of peroperative analgesia in prosthetic surgery of the lower limb. Prospective study of 68 cases

PURPOSE OF THE STUDY: Efficient peri-operative analgesia is more comfortable, allows earlier mobilisation and better functional results for lower limb arthroplasties. We report our 60 cases prospective study of combined spinal and epidural anesthesia, and expose interests of this technique to control peri-operative pain. MATERIALS: From 1994 to 1995, 60 patients ASA class 1 were operated: 45 total hip replacement (THR), 15 total knee replacement (TKR). The average age was sixty five years (range thirty nine to eighty five years). Combined spinal and epidural anesthesia was performed in every case. METHODS: In lateral decubitus position, a translucent 25 Gauge needle was introduced in L2-L3 interspace. In a first time spinal anesthesia was made with 20 mg Bupivacaine. In a second time, a lumbar epidural catheter was inserted. All patients received an epidural post-operative analgesia with 4 mg Morphine once a day during two days and intravenous Paracetamol. Visual analogue scale (0 to 10) (VAS) were recorded after the third post operative hour and every twelve hours. During this period satisfaction mark was also recorded (1 to 3). RESULTS: We didn't observe any case of respiratory depression or infection with the epidural catheter. We observed 10 cases of pruritus (one needed to stop protocol) and 18 urinary retentions. Six uretral catheters were necessary; we had one case of pyelonephritis (escherichia coli). The first micturition was obtained 13.5 hours after the end of surgery. For the fifty nine remaining patients, visual analogue scale was always inferior or equal to 2/10 and the satisfaction mark to 1/3. DISCUSSION: Different techniques allow peri-operative analgesia, but a few are efficient during the first two days. Plexus nerve blocks are simple and reliable but post-operative anesthesia is short (inferior to 15 hours). Intravenous morphine controlled by patients themselves with programmed display needs expensive and sophisticated material. The principal risk is respiratory depression. Epidural morphine has a lower respiratory depression risk, but needs a heavier technique. The principal problems is higher incidence of urinary side effects. Epidural anesthesia might tend to show a greater efficacity with the best visual analogue scale and satisfaction mark. CONCLUSION: The results indicate that combined spinal and epidural anesthesia for the management of peri-operative pain provide an excellent pain control with a daily morphine injection. For lower limb arthroplasties, visual analogue scale is always inferior or equal to 2 and satisfaction mark equal to 1.     

Latex allergy in the operating room: case report and a brief review of the literature

OBJECTIVE: To study whether the use of analgesic treatment in labour is influenced by ethnicity. DESIGN: A cross-sectional study of hospital patients. Setting; the two municipal hospitals, Ullev?l and Aker, in Oslo, Norway. Subjects; a total of 137 obstetrical patients, 67 Pakistani women and 70 Norwegian women. Main outcome measure; use of analgesics in labour. RESULTS: 30% of the Pakistani and 9% of the Norwegian women received no analgesia in labour. Pethidine injection was the preferred analgesic administered to Pakistani women. Women of Pakistani origin received epidural infusion or nitrous oxide and oxygen gas less frequently than Norwegian women. They also received fewer combinations of other analgesic methods. When adjusted for the mothers' age, parity and duration of delivery, Pakistani origin was the only significant predictor for receiving no analgesia in labour. CONCLUSION: Women of Pakistani origin were more than three times as likely not to receive analgesia in labour as Norwegian women. The health services offered to Pakistani women in labour were different from those offered to Norwegian women. These results indicate that women of Pakistani origin may be offered insufficient obstetrical analgesia, or that Norwegian women received unnecessary pain relief in labour.     

Erythrocyte Na/K ATPase activity and diabetes: relationship with C-peptide level

The purpose of this study is to clarify the volume effect of epidural saline injection 20 min after spinal anesthesia. Thirty patients undergoing combined spinal and epidural anesthesia for orthopedic surgery were randomly divided into two groups: a control group (n = 15) and a saline group (n = 15). In the control group, 2% lidocaine 3 ml with 0.4% tetracaine was injected into the subarachnoid space from L 4-5 interspace using Durasafe (Becton Dickinson, USA) and saline was not injected into the epidural space. In the saline group, saline 10 ml was injected through an epidural catheter 20 min after spinal anesthesia. The levels of analgesia 20 min after spinal anesthesia were not significantly different between the groups. However, the levels of analgesia 3, 5, 10, 40 and 100 min after epidural saline injection in the saline group were significantly higher than those in the control group (P < 0.05). The highest analgesic level was obtained 10 min after epidural saline injection and reached to T 4.3 +/- 1.1. In conclusion, epidural saline injection increases the analgesic level 20 min after spinal anesthesia because of the volume effect.     

Intrathecal sufentanil compared with epidural bupivacaine analgesia in labour

Epidural analgesia for pain relief during labour has certain disadvantages including slow onset. However, intrathecal sufentanil provides rapid onset and well-controlled analgesia lasting 1-4 h. The aim of this study was to compare the analgesia and the side effects of intrathecal sufentanil with epidural bupivacaine during labour. In a randomized, double-blind and controlled trial 58 parturient women requesting analgesia during labour were studied. The patients received either intrathecal sufentanil 10 micrograms and epidural saline, or intrathecal saline and epidural bupivacaine 20 mg. Visual analogue scores (VAS) for pain, blood pressure, heart rate, respiratory rate, level of sedation and the incidence of pruritus and nausea were recorded. Pain scores were significantly lower between 5 and 90 min after injection in patients receiving intrathecal sufentanil. Pruritus was significantly more frequent among those receiving intrathecal sufentanil. The rapid onset and effective analgesia of intrathecal sufentanil may in certain situations be advantageous.     

Cervical epidural steroid injection with intrinsic spinal cord damage. Two case reports

STUDY DESIGN: Intrinsic cervical spinal cord damage represents the serious and permanent complications that can occur if cervical epidural steroid injections are administered while the patient is sedated. Two case reports are presented. OBJECTIVES: To draw attention to the dangerous consequences that can arise from sedating a patient before administering a cervical epidural steroid injection. SUMMARY OF BACKGROUND DATA: Reported complications of cervical epidural steroid injections have been minor and infrequent. No reports of intrinsic cervical cord damage could be found in a comprehensive English language literature search. METHODS: Two case reports of permanent intrinsic cervical cord damage in patients who had been administered cervical epidural steroid injections while under intravenous sedation are presented. Magnetic resonance imaging was performed before and after the administration of cervical epidural steroid injections. Each patient had herniated nucleus pulposus before they received cervical epidural steroid injections and intrinsic cord damage on postinjection magnetic resonance images. RESULTS: Both patients developed increased pain and neurologic symptoms within 24 hours of injection. To date, these symptoms appear to be permanent. However, Patient 1 had pain relief in her right arm and shoulder after undergoing a microdiscectomy, but pain was still persistent in her left leg, and she has developed a positive Lhermitte's sign. CONCLUSION: These case reports indicate fluoroscopic guidance will not insure or prevent intrathecal perforation or spinal cord penetration during the administration of cervical epidural steroid injections. In addition, although intravenous sedations during cervical epidural steroid injections have been used numerous times without reported complications, it appears intravenous sedation in these two cases resulted in the inability of the patient to experience the expected pain and paresthesias at the time of spinal cord irritation. Therefore, the authors conclude that the patient should be fully awake during the administration of cervical epidural steroid injections, with only local anesthetic in the skin used for analgesia.     

Epidural fentanyl produces labor analgesia by a spinal mechanism

BACKGROUND: The purpose of this study was to determine if epidural fentanyl produces analgesia in laboring patients by a primary spinal or supraspinal action. METHODS: Fifty-four parturients were randomized to receive epidural 0.125% bupivacaine plus one of three treatments: epidural saline-intravenous saline, epidural fentanyl (20 microg/h)-intravenous saline, or epidural saline-intravenous fentanyl (20 microg/h). The study treatments were administered by continuous infusion, whereas epidural bupivacaine use was patient controlled. RESULTS: Epidural bupivacaine use was significantly reduced by epidural (11.5+/-4.6 ml/h) but not by intravenous fentanyl (15.9+/-4.5 ml/h) compared with saline control (16+/-5.9 ml/ h). Analgesia characteristics and side effects were similar among groups. CONCLUSIONS: Low-dose epidural infusions of fentanyl produce labor analgesia by a primary spinal action.     

Usefulness of radiologic monitoring of epidural catheters using epidurography

INTRODUCTION: Peridural analgesia involves a segmental block which at the thoracic level allows for early pulmonary recovery after chest or high abdominal surgery. The approach is difficult in children for reasons related to anatomy, maintenance, insertion of the catheter and dosing. OBJECTIVE: To report the radiologic monitoring of epidural catheter placement by epidurography as a technique for placing the epidural catheter in 17 patients for whom postoperative analgesia was to be provided by the same route. PATIENTS AND METHODS: Eighteen children (aged from 2 to 12) were given general anesthesia followed by epidural anesthesia. After catheterization of the epidural space, 1 or 1-5 ml of contrast was injected. Immediately afterwards an X-ray of the thoracic or lumbar spinal column, as appropriate to each case, was obtained. Epidural analgesia was provided with a mixture of bupivacaine 0.125% and fentanyl, in continuous perfusion or in fractionated doses. RESULTS: Placement of the catheter tip was confirmed in 17 cases by visualization of symmetry and the presence of contrast medium in the epidural space. In one case we observed extravasation of contrast medium, which had invaded the paravertebral space. The course was linear in 17 cases, with no looping. No complications related to injection of contrast medium were observed. CONCLUSIONS: Epidurography provides objective monitoring of tip placement and trajectory of epidural catheters, advantages which argue in favor of more frequent application of this imaging technique.     

Oral anticoagulant prophylaxis and epidural catheter removal

BACKGROUND AND OBJECTIVES: The use of regional anesthesia in patients receiving anticoagulants is controversial. The purpose of this review is to document the incidence of neurologic complications with insertion and removal of an epidural catheter in patients receiving oral anticoagulants and antiplatelet medication. METHODS: A retrospective review was made of the charts of 459 patients who underwent hip pinning or hip or knee replacement under regional anesthesia and received postoperative epidural analgesia and warfarin thromboembolism prophylaxis. The number of patients receiving preoperative antiplatelet therapy and warfarin, as well as baseline coagulation parameters, was documented. For patients who had postoperative epidural analgesia, the prothrombin time on the day of epidural catheter removal was obtained. Neurologic complications during the hospital stay were noted. RESULTS: Spinal anesthesia was administered to 47 patients and epidural anesthesia and postoperative analgesia to 412. Before surgery, antiplatelet therapy was given to 270 and warfarin to 180 patients, with some patients receiving both. The mean +/- SD preoperative prothrombin and partial thromboplastin times were 10.8 +/- 1.2 seconds (normal, 9.6-11.1 seconds) and 27.5 +/- 3.5 seconds (normal, 24.6-33.2 seconds), respectively. Blood on needle or catheter insertion was noted in 21 patients, all of whom were taking antiplatelet medication and/or warfarin. Epidural catheters remained postoperatively for a mean of 43.6 +/- 12.5 hours (range 5-118 hours). The mean prothrombin time on the day of epidural catheter removal was 14.1 +/- 3.2 seconds. Four postoperative peripheral neuropathies were detected. There was no clinical evidence of spinal hematoma in any patient. CONCLUSIONS: Epidural catheter placement and removal in patients taking oral anticoagulants appears to be safe. Careful monitoring of the patient for evidence of spinal hematoma after epidural catheter removal is recommended.     

An office approach to the diagnosis of chronic cough

BACKGROUND: Some cancer patients require invasive techniques for control of chronic cancer pain. Many patients have benefited from local administration of opioids and anesthetics through an epidural catheter. However, epidural abscess and meningitis are side effects of epidural catheters that have serious morbidity and mortality. METHODS: In a retrospective study, the charts of all patients who received an epidural catheter for the management of chronic cancer pain in a 3-year period (1993-1996) were reviewed. Patients with nervous system infections were identified and pertinent clinical, radiologic (magnetic resonance imaging), and bacteriologic data were analyzed. RESULTS: Ninety-one patients received 137 epidural catheters for a total of 4326 catheter days. All but four patients had died at the time of the final analysis. The median survival after placement of the first epidural catheter was 38 days (range, 1 day--> 1000 days). Seventy-two patients received a percutaneous port whereas 19 patients were treated with an implanted subcutaneous port. Adequate pain relief was obtained in 76% of the 58 patients with nociceptive pain and in 73% of 33 patients with neuropathic pain. All neuropathic pain was associated with active tumor and could be classified as nociceptive nerve pain. Technical complications and superficial infections occurred in as many as 43% of patients. Deep infections occurred in 12 patients, 11 of whom had a spinal epidural abscess. CONCLUSIONS: Deep infection is a frequent complication of epidural analgesia and is associated with a high morbidity and mortality. Only cancer patients with a short life expectancy (< or =3 months) should be treated with epidural analgesia.     

Temporary antibiotic-loaded cemented prosthesis for two-stage septic hip arthroplasty

BACKGROUND AND OBJECTIVES: Myofascial pain is the leading cause of chronic low back pain and in most cases can be successfully resolved with trigger point injections of local anesthetics. This type of pain can exist during pregnancy and exceed the analgesia provided by an epidural for labor. METHODS: A 31-year-old primiparous woman received an epidural infusion for labor analgesia. Despite complete resolution of labor pain and a solid, bilateral T10 block, the patient reported discomfort at two discrete locations in her right lumbar paraspinous muscle. RESULTS: The administration of local anesthetic via trigger point injections resulted in successful palliation of the myofascial pain. CONCLUSIONS: Myofascial pain can be an etiology of back pain in the parturient. Trigger point injections, even when used concomitantly with a functioning epidural infusion, can be a valuable aid for the provision of complete analgesia.     

Determination of provitamin A of green leafy vegetables by high performance liquid chromatography and open column chromatography

AIM OF STUDY: Intrathecal sufentanil has recently been used in labour as part of a combined spinal epidural technique. This study was conducted to compare its use in combination with bupivacaine for caesarean section with fentanyl added to bupivacaine and bupivacaine alone. METHODS: Sixty ASA I and II patients for non-emergency caesarean section under spinal anaesthesia were divided into three groups to receive 15 micrograms fentanyl added to 7.5 mg bupivacaine, 10 micrograms sufentanil added to 7.5 mg bupivacaine and 7.5 mg bupivacaine. Onset time of sensory blockade, side effects, surgical conditions, neonatal outcome and quality of the anaesthetic was assessed. On the first postoperative day, duration of effective analgesia, side effects and patient satisfaction were noted. RESULTS: The duration of effective analgesia of bupivacaine alone was prolonged with the addition of sufentanil and fentanyl by 358% and 256% respectively. No patient in the sufentanil and fentanyl groups required additional intra-operative analgesics compared with 17.6% of patients in the bupivacaine alone group. There was an increase in incidence of desaturation in the sufentanil group (45%) and fentanyl group (5.6%) compared with the bupivacaine only group (0%). The incidence of pruritus was 35% with sufentanil, 27.8% with fentanyl against 0% with bupivacaine alone. CONCLUSION: The addition of 10 micrograms of sufentanil and 15 micrograms of fentanyl to 7.5 mg of bupivacaine prolonged the duration of effective analgesia and improved intra-operative analgesia. However, the incidence of pruritus and episodes of desaturation were increased more with 10 micrograms sufentanil than with 15 micrograms fentanyl.     

150 years ago physicians and surgeons heeded the call of their country

PURPOSE: To evaluate the efficacy of ropivacaine 0.25% when administered epidurally for relief of labour pain and to compare it with bupivacaine 0.25%. METHODS: In a multicentre investigation, 60 ASA I and II labouring women were randomized in a double-blind fashion to receive either bupivacaine 0.25% or ropivacaine 0.25% administered epidurally by intermittent top-up for labour analgesia. Using a standardized technique, epidural analgesia was initiated after the woman received 10-15 ml-kg.1 crystalloid solution. Maternal blood pressure, heart rate, analgesia sensory level, degree of motor block and visual analogue pain scores were measured by the research nurse prior to, and at regular intervals, following the administration of analgesia. Total dose of local anaesthetic administered, duration of labour, mode of delivery, and maternal and fetal/neonatal side effects were noted. The fetus/neonate was assessed by the research nurse using the fetal heart rate tracing, Apgar scores at delivery and neonatal neurobehavioural assessments at 2 and 24 hr postnatally. Maternal and investigators' satisfaction with the analgesia achieved was assessed after delivery. RESULTS: No differences were found between the two agents in any of the variables studied. CONCLUSION: Ropivacaine 0.25%, when administered epidurally by intermittent top-ups for labour analgesia, was equally efficacious as bupivacaine 0.25%.     

Extensive epidural hemangioma with skin and bone involvement. A case report

STUDY DESIGN: This is a case report. OBJECTIVE: To report and to examine the clinical findings and management of epidural cavernous hemangioma. SUMMARY OF BACKGROUND DATA: Spinal epidural cavernous hemangiomatous malformation is a very rare entity. Only 20 cases of this disease have been reported in the literature. METHODS: The case of a 20-year-old woman with spinal epidural cavernous hemangioma was reviewed. RESULTS: The clinical presentation, diagnosis, and therapy of this disease are discussed. CONCLUSION: The treatment of epidural hemangioma consists of total or subtotal excision of the lesion, depending on the relation of the lesion to the spinal cord.     

Spinal epidural abscess. Optimizing patient care

The medical literature regarding spinal epidural abscess has two common threads: reports of poor prognosis and appeals for rapid treatment. Spinal epidural abscess is a difficult diagnosis to make because of its rarity--many physicians will never see a case during their careers. Among all patients admitted to hospitals, the incidence is approximately one to two cases per 10,000. Only increased awareness and swift management of spinal epidural abscess will improve outcome. Our goal through this report is to enhance the recognition and treatment of spinal epidural abscess. We present 28 new cases of spinal epidural abscess, giving special attention to the peculiarities of the disease; we compile and analyze comprehensive data from cases from literature; and finally, we present the results of 16 retrospective personal interviews of infected patients.     

Noninvasive evaluation of myocardial ischemia in Kawasaki disease: comparison between dipyridamole stress thallium imaging and exercise stress testing

PURPOSE: Reduction of the frequency of injections and localization of the absorption of drug molecules to the injection site would be of great advantage in epidural pain treatment. The epidural use of a controlled release gel of lidocaine and ibuprofen was studied. METHODS: The effect of a poloxamer gel (25%) containing 2% lidocaine.HCl and 2% ibuprofen.Na on the duration of analgesia after epidural administration to pigs was compared with drug in solution. Analgesia was assessed by observing the motor function and the nociceptive reflex-withdrawal response to painful pressure stimulation on the feet. Pharmacokinetic and histological examinations were performed. RESULTS: Analgesia lasted significantly longer after epidural lidocaine gel injection in comparison with the solution. The gel prolonged the systemic absorption, thereby increasing the epidural availability of lidocaine for spinal analgesia. Although the absorption of ibuprofen was prolonged after epidural gel injection, the duration of analgesia as compared with the solution was not prolonged. After epidural injection, only slight inflammatory changes were observed in the tissue structures of the epidural space, but none in the spinal cord. CONCLUSIONS: These results demonstrate poloxamer gel to be a promising controlled-release, injectable epidural formulation for the management of pain.     

Epidural spinal infection. Variability of clinical and magnetic resonance imaging findings

STUDY DESIGN: This study evaluates the magnetic resonance characteristics of spinal epidural abscesses and their associated disc space infections. OBJECTIVES: The results were correlated with history, clinical, and laboratory findings to provide guidelines for early and appropriate diagnosis of epidural spinal infections. SUMMARY OF BACKGROUND DATA: Imaging signs of spinal infections have been reported before, but not with special attention to early clinical and imaging findings. METHODS: Thirteen patients (10 men, 3 women; age range, 32-64 years) with progressive sensorimotor deficit were studied. All patients had a neurologic examination after admission and a magnetic resonance imaging scan done within the first 48 hours. In all cases, T1-weighted images before and after administration of gadolinium were obtained. T2-weighted images were acquired in eight cases as well. Ten patients subsequently underwent open surgery; in three cases, a percutaneous biopsy and drainage was performed. RESULTS: Cervical discitis was found in five patients, and thoracic discitis was seen in another five cases. Three patients had an epidural infection without a concomitant discitis. Neurologic and clinical findings varied considerably. Despite clinical signs of spinal cord involvement, a spinal cord lesion was demonstrated only once. Signal change in T2-weighted images may be the first sign of disc space infection. Because a neurologic deficit may occur before any change is visible, follow-up examinations may be required if epidural infection is suspected on clinical grounds. CONCLUSIONS: Magnetic resonance imaging is the appropriate method for diagnostic work-up of progressive neurologic deficit resulting from epidural infection.     

Early postpartum tubal ligation under epidural analgesia

Tubal ligation under epidural analgesia in the early puerperium (within 10 hours of delivery) was attempted in 51 patients who had an epidural block established during labour. The results are described. No major difficulties were encountered.