Uncommon Complications of Spinal Anaesthesia - Anesthesiaworld

Uncommon Complications of Spinal Anaesthesia – Anesthesiaworld http://www.anesthesiaworld.
net/uncommon-complications-sab/
Anesthesiaworld 
Anesthesia knowledge portal
Home Events Links About Us Contact
Search Uncommon Complications of

Spinal Anaesthesia
Quick Links  admin2014  February 22, 2015  Literature, PG section
ANTS  No Comments
Events: Conference and
Medication and technical errors continue to occur from time to
CME
time in anaesthesia practice contributing to preventable
Gallery
morbidity and mortality. In this literature review, rare and
Guidelines
delayed complications following spinal anaesthesia are
History
discussed.
Job Oppurtuities
Learning Centers 1. Accidental injection of wrong
Links
drugs into subarachnoid space
Literature
Non-Anesthesiologists Case report 1:
Participate
Intrathecal injection of tranexemic acid(Indian J Anaesth
PG section
2012;56:168-70, Mar-Apr 2012)
Practicing
Accidental injection of tranexemic acid into subarachnoid space
Anesthesiologist
of 37 year old lady, ASA PS I posted for cystolithotripsy
Weekend Questions
1 of 14 4/29/16, 11:06
Uncommon Complications of Spinal Anaesthesia – Anesthesiaworld http://www.anesthesiaworld.net/uncommon-complications-sab/
Recent Posts
Non Invasive Ventilation
Perioperative cardiac
arrest: Causes,
Management and
Prevention
Vasopressors in
Similar Ampoules of Bupivacaine and Tranexamic
anaesthesia and critical
acid
care: what we should
know?
Peripheral Venous Access
Following spinal, patient complained of severe burning pain in
Bimanual Laryngoscopy
both lower limbs, back and gluteal region, and was irritable.
Myoclonic movements were noticed in the lower extremities.
Patient was managed with anticonvulsants, intensive
Recent Comments haemodynamic monitoring, and CSF lavage. The ampoules of

Bupivacaine (5 mg/mL, trade name “Sensovac Heavy”) and
admin2014 on PG EXCEL
tranexamic acid (500 mg/ml, Trade name “Nexamin”) were
2016
similar in appearance.
Dr Dinesh G on PG
EXCEL 2016 Recovered fully without any neurological sequelae within 1
week
Previous similar reports:

Archives Wong et al. (Ma Zui Xue Za Zhi 1988; 26:249-52) reported the
RCDE42D6@7:?25G6CE6?E:?EC2E9642=:?;64E:@?@7>8EC2?6I2>:4
March 2016
acid in an 18-year-old man scheduled for appendicectomy. He
December 2015
developed clonic convulsions that progressed to a generalized
November 2015
seizure, which treated with intravenous diazepam, and the
March 2015
patient recovered without any sequelae.
February 2015
January 2015 De leede et al. (J Neurol 1999; 246:843) has reported a case of
May 2014 a 68-yearold man who accidentally received an intrathecal
April 2014 injection of 50 mg. tranexamic acid. Immediately after the
injection, he developed status epilepticus. The outcome was
complicated, with hypotonic paresis of all four limbs, which
resolved but resulted in residual bilateral peroneal palsy.
Job listing Yeh et al. (Anesthesiology 2003; 98:270-2) reported that
Dedicated anesthetist D6:KFC6D2?5C67C24E@CJG6?EC:4F=2CR3C:==2E:@?27E6C244:56?E2=
intrathecal administration of 500 mg tranexamic acid were
associated with fatal outcome.
2 of 14 4/29/16, 11:06
Case report 2:
User
Accidental spinal potassium chloride injection successfully
Login
treated with spinal lavage (Anaesthesia 2014, 69, 72–76).
Logout
Register A 62-year-old man weighing 75 kg, known hypertensive was
scheduled for right total hip replacement under spinal
anaesthesia. Ten minutes after injection, there was only patchy
blockade, the loss of sensation being inadequate for the
Events planned surgery. Spinal anesthesia was again repeated with the
Ganga Anaesthesia same drug dosage once more. Immediately after the second
16/06/2016 - injection the patient started to complain of severe pain, pruritus,
19/06/2016 cramps, progressive weakness in both lower limbs (left more
Coimbatore than right) and marked sweating. There was complete
KSHEMA PACE 2016 anaesthesia below the T10 level with hypertension and
09/07/2016 - tachycardia.
10/07/2016
Antihypertensive treatment was started. Ten minutes after the
Mangalore
second injection, the sensory level had risen to T4; there was
ISACON SOUTH 2016
S244:5A2C2A=68:2H:E9=@DD@7566AE6?5@?C6S6I6D2?5A2:?:?
19/08/2016 -
3@E9=@H6C=:>3D6C63C@DA:?2=SF:5=2G286H2D5@?6
21/08/2016
Immediately after the lavage, the patient developed signs and
Belagavi
symptoms of pulmonary oedema; this required sedation,
NAC 2016
tracheal intubation and mechanical ventilation.
16/09/2016 -
18/09/2016 Eight hours after the lavage, the patient became
Vadodara haemodynamically stable, and started to move his legs and then
was extubated. cutaneous sensation had returned to normal. A
magnetic resonance scan of both thoracolumbar spine and
brain was normal
+(4(9(4(121(742/2*,&$/'(?&,65$1'6+(5,*152)$762120,&
hyperactivity had disappeared
3 of 14 4/29/16, 11:06
Similar Ampules of Bupivacaine and

Magnesium Chloride
2. Necrotising fascitis
(Indian Journal of Anaesthesia | Vol. 57| Issue 3 | May-Jun
2013)
Case report:
A 27-year-old parturient, ASA I PS received uneventful spinal

anaesthesia for caesarean section delivery. Patient was
admitted in the emergency department with severe pain,
swelling, erythema and blackening involving nearly whole of the
back, part of anterior abdomen and gluteal regions
accompanied by fever and chills 20 days days following delivery.
There was no history of diabetes mellitus, chronic infections,
immunosuppressive medications intake and leukemias or
lymphomas.
Despite of intensive management of septic shock patient died

on third day.
4 of 14 4/29/16, 11:06
Nectrotizing Fascitis
3. Intraspinal and intracranial

subarachnoid hemorrhage with
severe cerebral vasospasm
Intraspinal combined with cerebral subarachnoid hemorrhage
has been rarely reported as a complication after lumbar spinal
anaesthesia. Acute intracranial and intraspinal subarachnoid
hemorrhage after lumbar puncture is a rare but life threatening
complication, requiring urgent diagnosis and therapy.
A 35-yr-old multigravida at 34 week gestation with antenatal

history of arterial hypertension and polycystic kidney disease,
admitted for forceps delivery under spinal anesthesia.
2 days following spinal anaesthesia, the patient developed

severe back pain, headache, vomiting, and stiff neck. Despite
analgesia and antiemetic treatment, symptoms increased in
:?E6?D:EJH:E9A2C2A=68:2@?R7E952JA@DEA2CEF>@>AFE65
tomography showed evolving subarachnoid hemorrhage. Spinal
magnetic resonance imaging (MRI) showed a late sub acute
subarachnoid bleeding between T5 and 10 with mass effect on
the spinal cord. A complete T10–11 and partial T9 bilateral
decompressive laminectomy was performed to remove subpial
clots from a vascular malformation compatible with a spinal
angioma. Following surgery patient was conscious and oriented
but had lower limb paralysis and hypoesthesia from T6.
Antihypertensive therapy for cerebral vasospasm was started.
On the third day in PACU, headache and stiff neck increased
5 of 14 4/29/16, 11:06
along with nausea and vomiting. Cranial MRI showed

subarachnoid hemorrhage and hemoventricle in both occipital
poles. Conservative treatment with calcium antagonists and
antihypertensive agents was maintained. On the sixth day,
patient suffered a neurological deterioration with paralysis of the
upper left limb and impaired consciousness [Glasgow coma
scale (GCS) 5] proceeding to sedation, intubation, and assisted
ventilation. With transcranial Doppler ultrasound, a severe
vasospasm in both middle cerebral arteries (MCAs) appeared.
Cerebral arteriography was performed with balloon angioplasty
and intra-arterial verapamil, with a partial recovery of right MCA
42=:3C62?55:DE2=3=@@5S@H:>AC@G6>6?EH:E94@>A=6E6
recovery in left MCA. After resolution of cerebral vasospasm,
the patient regained consciousness and could be extubated in
the following hours.
$6FC@=@8:42=6I2>:?2E:@?D9@H65)S244:5F?C6DA@?D:G6
paraplegia, and hypoesthesia from T6. The patient was
discharged to a specialized centre for rehabilitation.
4. Intracranial Sub Dural hematoma

Rev Bras Anestesiol 2012;62:1;88-95
Case report: 48 year old female, ASA 1PS, with urinary

incontinence, uneventful spinal anesthesia with 27 G needle.
Symptoms started after 48h with intense headache and other

neurological symptoms, which necessitated surgical evacuation
after 17 days of conservative management.
Outcome: complete recovery
6 of 14 4/29/16, 11:06
5. Subdural hygroma
(Anesth Analg 2002;94)
72 year old otherwise healthy female received spinal

anaesthesia at L4-5 with whitacre needle 25G uneventfully.
On D2 she had headache not responding to analgesics and was

discharged after a week.She was re admitted at 3 weeks with
progressive drowsiness and headache.there was no evidence of
raised ICP.Investigations showed bilateral subdural hygromas
and patient received dexamethasone. An epidural blood patch
was performed with autologous blood, 15ml at the same space.
Completely recovered.
6. Cauda Equina syndrome with

profound hearing loss
Anesth Anag 2006;102:1863-64)
Case report:33 year old, male,ASA 1 posted for anorectal

surgery in lithotomy position, received uneventful spinal
anesthesia with 22 G needle with isobaric bupivacaine.
He developed symptoms of cauda equine syndrome and

profound hearing loss with 8h of spinal anesthesia, which
persisted even after 21 months. Hearing loss was suggestive of
cochlear pathology.
A previous study suggested that hearing loss after spinal could

be related to needle size (Anesth Analg 1990;70:517-522).Also
case reports are available on cauda equina syndrome with both
lignocaine and bupivacaine.
7. Foot drop
(Indian J Anaesth 2011;55,Can J Anesth 2005;52,Rev Bras
Anestesiol 2014)
Usually unilateral, but occasionally bilateral foot drop cases

have been reported in the literature, though the exact
mechanism is not known. It can follow otherwise uneventful
spinal anesthesia as well
7 of 14 4/29/16, 11:06
8. Neurological complications
following spinal anaesthesia in a
patient with congenital absence of
lumbar vertebra
(Indian Journal of Anaesthesia 2014;58(4):484-486)
A 25‑year‑old, short stature (130 cm), ASA I PS received

uneventful spinal for caesarean delivery. She was admitted to
neurosurgical Intensive Care Unit with complaints of inability to
move both lower limbs and bladder and bowel incontinence 6
days after delivery. The patient was non‑diabetic and
normotensive. Patient had a history of surgery for swelling over
lower back in infancy which was present since birth.
Neurological examination revealed complete motor, sensory and

autonomic loss of sensation below L2 level with involvement of
bladder and bowel. An X‑ray lumbosacral spine and magnetic
resonance imaging (MRI) of the spinal cord revealed congenital
absence of L3‑5 lumbar vertebrae with low lying spinal cord at
L2 level, with myelitis and arachnoiditis. L2 vertebrae were
directly fused to the sacrum without any other deformity at that
level. A probable diagnosis of chemical myelitis or direct injury
to the cords was suspected. Patient was treated conservatively
on rest and high doses of steroid (methyl prednisolone) to which
she responded partially after 6 weeks in the form of motor
recovery. There was no improvement in bladder and bowel
function after 2 years.
9. Broken needle

Result of defective construction of needle. The needle breaks at
the junction of the hub with the shaft of the needle. Disposable
needles are associated with greater risk.
10. Cardiac arrest

It is the most dreaded complication for the anesthesiologist,
more so when it occurs in an apparently healthy person. There
are several such case reports in literature, main sources being
closed insurance claims and retrospective reviews.
8 of 14 4/29/16, 11:06
During an early review of the Closed Claims Database it was

found that few healthy adult patients experienced sudden
cardiac arrest while receiving conventionally-managed spinal
anesthesia for relatively minor surgery. The outcome in all cases
was death or brain damage. Recurrent patterns of presence of a
high level of block of T4, the rapid onset of cardiac arrest
approximately 30 minutes after the initiation of spinal anesthesia
and the presence of apparently stable hemodynamics and
respiration preceding sudden deterioration were seen in about
half of the cases. Although cardiopulmonary resuscitation was
promptly initiated, epinephrine was not administered until an
2G6C286@7>:?FE6D9256=2AD65*96D6R?5:?8DDF886DEE92E
:?DF7R4:6?EC6DE@C2E:@?@7A6C:A96C2=G2D4F=2CE@?6M6DA64:2==J:?
the setting of high sympathetic blockade – may contribute to the
severity of cardiac and neurologic outcome. Spinal anesthesia
decreases coronary perfusion pressure during CPR to levels
below the threshold for successful resuscitation. Administration
of exogenous epinephrine or vasopressin helps to achieve
critical threshold of perfusion pressure.
In a recent review of high severity injuries associated with

regional anesthesia claims in the 1990’s, 30 claims were found
in which death occurred. Of these 30 claims, cardiac arrest
during central neuraxial block accounted for one-third of cases
and was the single largest cause of death. The current literature
contains at least 41 well-documented case reports in which a
circulatory mechanism – not respiratory depression or lack of
vigilance – played the primary role in sudden cardiac arrest
during spinal or epidural anesthesia. Vagal factors (traction,
movement, pitocin, fear, athletic heart) were often reported in
these new cases.
Caplan et all reported in a review of closed insurance claims.14

cases of sudden cardiac arrest in otherwise healthy patients
after spinal anaesthesia. Hypoxia and over sedation could be
contributing factors.
The incidence of cardiac arrest in different review varies from

0.04-6.5/10000 cases of spinal anaesthesia.
In a multicentre study in Thailand (Regional Anesthesia, Vol

107,No 5 November 2008), 11 cases of cardiac arrest were
reported among 40,271 spinal anesthetic, with death as the
9 of 14 4/29/16, 11:06
outcome in more than 90% of cardiac arrests. The patients

involved were both obstetric (5 cases) and non obstetric
(6cases).Contributing factors included high blockade, blood
loss, hypovolemia, lack of ECG monitoring and spinal given by
surgeons due to non availability of anesthetists. Neither
bradycardia nor fall in saturation was present in all patients.
Role of undiagnosed pathology should always be kept in mind
Coronary artery spasm

(Journal of clinical anaesthesia 1996;8)
42 year, male, ASA I for testicular tumor excision, received

spinal anesthesia with tetracaine and dibucaine.
Patient complained of back pain with peritoneal stimulation and

had mild hypotension.Inj pentazocine was given without any
effect. Subsequently patient developed hypotension and
D:8?:R42?E)*6=6G2E:@?@?H:E9@FE2?J496DEA2:?62CE
rate was 62/min. He was successfully treated with a dose of
ephedrine IV and nitroglycerine infusion resulting in complete
and uneventful recovery
Paraplegia after spinal anaesthesia

82 year old patient posted for management of urinary retention

due to prostatic hypertrophy. .Had history of
hypertension,COPD, hyperplastic thyroid and mild CAD.
Spinal was administered with 25G Quinke needle at L5 S1

space with hyperbaric bupivacaine. Patient developed signs and
symptoms of paraplegia below T1 level 36h postoperatively.
Imaging ruled out epidural abscess but showed a mass
extending from T4 to T6.A CT guided biopsy of the mass
showed it to be tubercular granuloma.
Cranial nerve involvement

Incidence varies from none to 5%. Of the disturbances 60%
involve sixth nerve, and 30% involve seventh nerve, 10%
involve other cranial nerves. Sixth cranial nerve most commonly
10 of 14 4/29/16, 11:06
involved as it has the longest intracranial course and is

vulnerable to dynamic changes in the ‘water cushion’ of the
CSF.
Visual disturbances
Ischemia of the optic and other ocular muscles is considered
the likely cause of most visual disturbances. Causes are low
perfusion from systemic hypotension, low ICP from CSF
leakage, Gravity traction on the cranial nerves.
D i ve r g e n t p a r e s i s w i t h o u t p o s i t i o n a l
headache
Case report: 64 year old male for prostatectomy for benign

hypertrophy of prostate.20G cutting spinal needle and dibucaine
local anesthetic were used in otherwise uneventful spinal
anesthesia at L4-5.
Patient developed divergent paresis on D17 without evidence of

abducent nerve palsy. It was characterized by horizontal
diplopia for distant objects, more than 2 meter distance. There
was no nystagmus. The condition was thought to be due to CSF
9JA@G@=6>:22D492C24E6C:K653J#(R?5:?8D3D6?46@7
positional headache, a characteristic of CSF hypovolemia was
unusual in this patient.
Completely recovered by D46.
Epidural abscess
Can result from contamination of epidural space and is due to
faulty spinal puncture technique.
Septic meningitis
Can occur due to inadequate sterilization of equipment,
bacterial contamination of the anesthetic agents, or the
introduction of the spinal needle through the infected tissue.
Meningismus
E:D@?6@7E96?@?:?764E:G64@>A=:42E:@?D5F6E@:?S2>>2E:@?
of meninges resulting from coming into contact with the
11 of 14 4/29/16, 11:06
chemicals like iodine used for skin preparation. Occurring quite

suddenly and usually during third and fourth day, it presents as
intense headache, neck stiffness, positive kernig’s sign and
photophobia. It is non progressive and subsides with treatment
and antibiotics.
Cauda equina syndrome

(BJA 2000; 84 121-6)
Albert Wolley and Cecil Roe became paraplegic following spinal

2?26DE96D:27@C>:?@CDFC86CJ:?96DE6CR6=5(@J2=9@DA:E2=:?
1947. Spinal anaesthesia was given by the same
anesthesiologist, with the same drug on the same day in the
hospital. The most probable cause of paralysis was an acidic
descaler that was allowed to remain in the sterilizing water
boiler. The spinal needles and syringes were then boiled in acid
which subsequently contaminated the spinal anaesthetic
solution when it was withdrawn from the ampoule before
injection.
Transient Neurological Symptoms (TNS)

Earlier this condition was called transient radicular irritation.
Though traditionally believed to occur with lignocaine intrathecal
administration, especially with 5% hyperbaric, it has been
described with every local anesthetic. Lignocaine and
mepivacaine are more commonly associated with TNS than
bupivacaine and could be due to drug per se, dextrose of
epinephrine. Symptoms of pain in the buttocks radiating to legs,
unilateral or bilateral is most common presentation. Onset is
within 24 hours of spinal anaesthesia and spontaneous and
4@>A=6E6C64@G6CJ:DE96CF=6*JA6@7?665=62=D@42?:?SF6?46
the development of TNS.
Pulmonary embolism
In elderly orthopedic patients with hip fractures, who are often
bed ridden, movement of the limb for fracture reduction on the
table after spinal anaesthsia, can lead to pulmonary embolism
and sudden cardiac arrest (personal experience).This is not
directly related to spinal anaesthesia, but occurring immediately
27E6CDA:?2=:E92DD:8?:R42?467@CE962?26DE96D:@=@8:DE
12 of 14 4/29/16, 11:06
Take home messages……….

Neither healthy patients nor apparently uneventful spinal
anesthesia does not totally preclude development of
complications.
Outcome can vary from complete recovery to neurological
56R4:E@C562E9
Wrong drug administration still continues to occur, with
disastrous consequences
CSF lavage was found to be extremely useful when a
HC@?85CF825>:?:DEC2E:@?:D:56?E:R65
All patients should receive aggressive symptomatic and
supportive treatment
Obstetric patients are at higher risk of complications due to
spinal anesthesia
Authors: Dr Suchitha, Dr Raveendra U S

SShhaarree tthhiiss::
 Facebook 1  Google  Twitter  Print  Email

 Pocket
← APPROACH TO DIFFICULT AIRWAY
Percutaneous Dilatational Tracheostomy ( PCDT ) →
Leave a Reply
Your email address will not be published.(6BF:C65R6=5D2C6
marked *
Comment
Name *
13 of 14 4/29/16, 11:06
Email *
Website
post comment
Notify me of follow-up comments by email.
Notify me of new posts by email.
Copyright © 2016 Anesthesiaworld. Theme by Colorlib Powered by WordPress
14 of 14 4/29/16, 11:06

Uncommon Complications of Spinal Anaesthesia - Anesthesiaworld

Enviado por

Dados do documento

Título original

Direitos autorais

Formatos disponíveis

Compartilhar este documento

Compartilhar ou incorporar documento

Opções de compartilhamento

Você considera este documento útil?

Este conteúdo é inapropriado?

Direitos autorais:

Formatos disponíveis

Uncommon Complications of Spinal Anaesthesia - Anesthesiaworld

Enviado por

Direitos autorais:

Formatos disponíveis

Uncommon Complications of Spinal Anaesthesia – Anesthesiaworld http://www.anesthesiaworld.

Home Events Links About Us Contact

Search Uncommon Complications of

Recent Comments haemodynamic monitoring, and CSF lavage. The ampoules of

Previous similar reports:

16/06/2016 - injection the patient started to complain of severe pain, pruritus,

19/06/2016 cramps, progressive weakness in both lower limbs (left more

Coimbatore than right) and marked sweating. There was complete

Similar Ampules of Bupivacaine and

A 27-year-old parturient, ASA I PS received uneventful spinal

Despite of intensive management of septic shock patient died

3. Intraspinal and intracranial

A 35-yr-old multigravida at 34 week gestation with antenatal

2 days following spinal anaesthesia, the patient developed

along with nausea and vomiting. Cranial MRI showed

4. Intracranial Sub Dural hematoma

Case report: 48 year old female, ASA 1PS, with urinary

Symptoms started after 48h with intense headache and other

Outcome: complete recovery

72 year old otherwise healthy female received spinal

On D2 she had headache not responding to analgesics and was

6. Cauda Equina syndrome with

Case report:33 year old, male,ASA 1 posted for anorectal

He developed symptoms of cauda equine syndrome and

A previous study suggested that hearing loss after spinal could

Usually unilateral, but occasionally bilateral foot drop cases

A 25‑year‑old, short stature (130 cm), ASA I PS received

Neurological examination revealed complete motor, sensory and

9. Broken needle

10. Cardiac arrest

During an early review of the Closed Claims Database it was

In a recent review of high severity injuries associated with

Caplan et all reported in a review of closed insurance claims.14

The incidence of cardiac arrest in different review varies from

In a multicentre study in Thailand (Regional Anesthesia, Vol

outcome in more than 90% of cardiac arrests. The patients

Role of undiagnosed pathology should always be kept in mind

Coronary artery spasm

42 year, male, ASA I for testicular tumor excision, received

Patient complained of back pain with peritoneal stimulation and

Paraplegia after spinal anaesthesia

82 year old patient posted for management of urinary retention

Spinal was administered with 25G Quinke needle at L5 S1

Cranial nerve involvement

involved as it has the longest intracranial course and is

Case report: 64 year old male for prostatectomy for benign

Patient developed divergent paresis on D17 without evidence of

Completely recovered by D46.

chemicals like iodine used for skin preparation. Occurring quite

Cauda equina syndrome

Albert Wolley and Cecil Roe became paraplegic following spinal

Transient Neurological Symptoms (TNS)

Take home messages……….

Authors: Dr Suchitha, Dr Raveendra U S

 Facebook 1  Google  Twitter  Print  Email

← APPROACH TO DIFFICULT AIRWAY

Percutaneous Dilatational Tracheostomy ( PCDT ) →

Notify me of follow-up comments by email.

Notify me of new posts by email.

Copyright © 2016 Anesthesiaworld. Theme by Colorlib Powered by WordPress

Você também pode gostar