Anesthesiology Clin N Am 20 (2002) 665 667

Complications of regional anesthesia: an overview

Bruce Ben-David MD
University of Pittsburgh, Department of Anesthesiology, A 1305 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15261, USA

A great deal of print has been devoted to the techniques of regional anesthesia. As important as these are, it is no less important that the clinician be familiar with the complications of these techniques. Indeed, that which distinguishes the physician from the technician is a thorough knowledge of potential complications and their management. Perhaps the clearest picture of the numbers and types of injuries from regional anesthesia is provided by the ASA Closed Claims Project database [1]. In reviewing these data, it is valuable to keep in mind, of course, that the lack of a denominator makes the calculation of incidence impossible. For the decade of the 1990s, 308 claims were associated with regional anesthesia (versus 642 claims associated with general anesthesia). The percentage of these claims for patient death (10%) continued its steady decline from more than 20% in the 1970s and 13% in the 1980s. The primary reason for death remains cardiac arrest associated with neuraxial blockade, though this now represents only 30% of the deaths as opposed to 61% in the 1970s and 40% in the 1980s. There were 71 permanent disabling injuries among the 308 claims. The most common of these (23%) was associated with nerve blocks of the eye (13 retrobulbar, 3 peribulbar), and typically the injury entailed loss of vision. Second in frequency (21%) were pain-management related claims involving, for example, neuraxial opiates or neurolytic blocks. Third in frequency (20%) were nerve injuries associated with neuraxial and peripheral blocks followed by epidural hematomas (13%). As a reflection of anesthesiologists increasing involvement in pain management, there has been a significant rise in the percentage of claims arising from pain management in a nonoperative setting (8%, 1990s; 2.8%, 1980s; 2%, 1970s) [2]. Anesthetic blocks accounted for 84% (202/241) of these claims in the database. Of this group neuraxial blocks represented 55% (120/202) of claims, sympathetic blocks 16%, axial nerve blocks 15%, and other blocks 9%.

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B. Ben-David / Anesthesiology Clin N Am 20 (2002) 665667

The most common adverse reactions associated with anesthetic blocks were nerve injury or paralysis (23%), pneumothorax (19%), postdural puncture headache (11%), and death or brain injury (10%). In the subset of 120 claims associated with neuraxial blocks, 78% involved the injection of epidural steroid. The most common injuries in that group of 93 patients were postdural puncture headache (23%), nerve injury or paralysis (22%), death or brain damage (11%), and meningitis (11%). Just as these figures present but a broad overview, so these two chapters on peripheral and neuraxial blockade are intended as a general survey of the topic, organized conceptually rather than by specific nerve blocks. They are not intended as a compendium of all possible complications of regional anesthesia but rather as a framework in which to consider them. The complications of regional anesthesia can be broadly grouped into four categories: (1) psychogenic reactions, (2) coincident complications, (3) trauma from the technique, and (4) untoward effects of the local anesthetic and adjuvant drugs. Fear and patient discomfort or pain may accompany any regional technique, and the gamut of psychogenic reactions is common to all of regional anesthesia. These reactions include anxiety and agitation as well as vasovagal reactions with, on occasion, severe bradycardia, hypotension, loss of consciousness, and even seizure. Therefore, the judicious use of sedation and analgesia is usually advisable, and basic monitoring should be routine. The term coincident injuries is used here to refer to those injuries occurring during the time of a nerve block that either are completely unrelated or are related in an indirect fashion. The former type of injury is often attributed unjustly to the anesthetic. Not uncommonly, however, careful examination and testing reveals the location and thus the etiology of the injury to be otherwise. Meralgia paresthetica (lateral femoral nerve injury) or femoral nerve injury following lower abdominal surgery are surgical injuries (eg, retractor stretching of the nerves) often attributed to an epidural. Likewise maternal injuries from childbirth, such as obturator nerve injury, may well be ascribed to the epidural. Another example of coincident injury is nerve or other tissue injury secondary to excessive pressure or duration of an intraoperative tourniquet. It is important for the practitioner to be aware of the possibility of coincident injury because it is likely to be encountered in the course of practice. Neural blockade may also indirectly contribute to injury of an extremity as a result of malpositioning (joint injury, nerve compression) intraoperatively or postoperatively. Diagnosis of a compartment syndrome may be obscured or delayed by postoperative neural blockade. Therefore, caution must be used in positioning and guarding a blocked extremity(ies) during and following surgery, and the extremity(ies) should be examined periodically until regression of the block. The two latter categories of complications, those secondary to trauma from the technique and those resulting from the effects of local anesthetic and adjuvant drugs, comprise most complications of regional anesthesia, both peripheral and neuraxial. These are discussed in further detail in the two chapters to follow.

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References
[1] Cheney FW. High-severity injuries associated with regional anesthesia in the 1990s. American Society of Anesthesiologists Newsletter 2001;65:6 8. [2] Fitzgibbon DR. Liability arising from anesthesiology-based pain management in the nonoperative setting. American Society of Anesthesiologists Newsletter 2001;65:12 15.