Regional Anesthetic

Complications
Vincent Conte, MD
Associate Clinical Professor
Nurse Anesthesia Program
FIU College of Nursing and Health
Sciences

RA Complications

1)
2)

Presentation divided into two

sections:
Contraindications
Complications (both Spinal &
Epidural)

Assessment

If a neuraxial anesthetic is being considered,

the risks and benefits need to be discussed
with the patient
An INFORMED CONSENT needs to be
obtained prior to performing any neuraxial
anesthetic
A careful H & P and PE need to be done to
make sure there are no CONTRAINDICATIONS
to performing a neuraxial anesthetic

Assessment

Patients should understand prior to their

block, that once the block is performed
they will have little or no motor function
until the effects of the block wears off
Patients should also be warned that
once the block takes effect, they may
feel like their limbs are in various
positions (straight up, bent or folded,
etc.) but are really still and flat against
the bed or any rests or padding that you
provide

Physical Exam
Prior to ANY Spinal or Epidural
anesthetic, a CAREFUL examination
of the back should be made. Things
to look for are:
Surgical Scars
Scoliosis
Skin lesions
Palpable Spinous Processes

Physical Exam

Although no preoperative screening

tests are required for healthy
patients undergoing neuraxial
blockade, coagulation studies and
platelet count should be checked
when clinical history suggests the
possibility of a bleeding diasthesis

Contraindications

1)

There are certain ABSOLUTE

contraindications to Regional
Anesthesia:
Infection at the site:
Could theoretically pre-dispose
patients to hematogenous spread of
the infectious agents into the
epidural or subarachnoid space

Contraindications
2) Patient Refusal: Any denial by the
patient should end there and then; DO
NOT continue to try to convince a
patient for regional anesthesia unless
you have a valid medical reason to
persist; even then a NO is a NO!!!!
Just make sure you document that the
patient was offered a regional and
risks/benefits were explained, but
patient refused

Contraindications
3) Coagulopathy or other Bleeding
Diasthesis: Do I really need to
explain why not in these
circumstances????
(Just Kidding) If they cant clot then
you stick the minimum number of
needles into a patient (hopefully just
an IV and that is it!!)

Contraindications
4) Severe Hypovolemia: Any
sympathectomy will compound the
hypotension TREMENDOUSLY
5) Increased Intracranial Pressure:
Any increase can lead to a brain
stem herniation if a spinal is
performed and even a minute
amount of CSF is lost

Contraindications
6) Severe Aortic Stenosis: Any change
in SVR or preload and hypovolemia can
result in SEVERE myocardial ischemia
and Sudden Cardiac Death; NOT GOOD
7) Severe Mitral Stenosis: Any change
in SVR can lead to sudden Right Heart
failure and rapid onset of Pulmonary
edema

Relative
Contraindications
Relative Contraindications are:
1) Systemic Sepsis: For the same reason as
an infection at the site, if bacteremia
exists, it can be possible to seed the CNS
during your procedure (For me, its a NO
GO) Also, systemic sepsis is usually
accompanied by Relative Hypovolemia
(peripheral vasodilation) which can
become much worse with an added drop
in SVR from your block

Relative
Contraindications
2) An Uncooperative Patient:
Regional anesthesia requires at least
some degree of patient cooperation.
This may be difficult or impossible for
patients with dementia, psychosis, or
emotional instability (MOST OF
YOU!!!)

Relative
Contraindications
3) Preexisting Neurological
Deficits: Patients with preexisting
neurological deficits may report that
their symptoms are worse following a
block (Usually through their Lawyer!!)
It may be impossible to discern
effects or complications of the block
from preexisting deficits or unrelated
exacerbation of preexisting disease

Relative
Contraindications
3) Careful documentation is a MUST in any
patient with preexisting neurological
deficits and documentation of an
explanation of risks/benefits and possible
worsening of symptoms is
MANDATORY!!!!! (To me, another NO GO)
This is a major source of liability
connected with the use neuraxial
blockade

Relative
Contraindications
4) Stenotic Valvular Heart Lesions: The
management of any valvular heart lesion
suggests minimal to moderate decreases in
SVR (encourage forward flow) and keeping
the heart rate normal to slightly decreased (to
allow more filling times). The use of Regional
Anesthesia can accomplish a reduction in SVR
but you will usually have a compensatory rise
in heart rate and sometimes the drop in SVR
can be very precipitous

Relative
Contraindications
4) Stenotic Valvular Lesions (contd):
In light of these possible complications,
IF the use of a Regional Anesthetic is
planned, it may be more prudent to use
an Epidural and SLOWLY titrate the level
of surgical anesthesia via the catheter
to minimize the drop in SVR with
compensatory increase in heart rate

Relative
Contraindications
4) Stenotic Lesions (contd): The
presence of any valvular heart lesions
requires a consultation with Cardiology
(if time permits) but most experts
recommend AVOIDING a regional
anesthetic in the face of SYMPTOMATIC
Stenotic lesions, and to USE WITH
CAUTION in any stenotic lesions that
are ASYMPTOMATIC and use an Epidural
rather than a spinal and take your time
to titrate the level of anesthetic needed

Relative
Contraindications
5) Severe Spinal Deformity: Many
anesthetists feel that in the face of
severe scoliosis or spinal deformity, the
spread of local anesthetic may be
altered to such an extent that a high
spinal can easily be obtained, or that
adequate surgical anesthesia may not
be able to be accomplished due to the
abnormal spread and distribution
secondary to the deformity (My rule is
that if it looks real funky and twisted, it
is a NO GO)

Controversial
Contraindications
1) Prior surgery at the site of injection:
After back surgery, the anatomy can be
altered tremendously and you may loose the
ability to find the epidural space. The
spread of your local anesthetic can be
altered to a large extent and render your
anesthetic useless
(My rule is if surgery has been at one level,
you can do a spinal at a level below BUT an
Epidural will probably fail or end up in a
Dural Puncture and is a NO GO; if multiple
levels have been worked on, it is a NO GO
from the start because the anatomy will be
too abnormal, even for a spinal)

Controversial
Contraindications
2) Inability to communicate with the
patient: With dementia, previous stroke with
loss of speech, or with any psychiatric
condition that makes communication difficult
or impossible, you cannot assess the presence
of any signs and symptoms of intravascular
injection or high spinal so if you DO use a
Regional anesthetic on these patients, you
must be VERY CAREFUL about watching your
patient for vital sign changes that may indicate
adverse reactions

Controversial
Contraindications
3) Complicated Surgery: With any
complicated surgery, several factors
may make a Regional NOT the best
choice.
a) Possible long (>3 hours) surgery
can become very uncomfortable for the
patient and require increasing levels of
sedation that may compromise
respiratory function

Controversial
Contraindications
3) b) If the possibility of major blood
loss exists, your potential drop in SVR
from your regional can be
compounded to a severe level. Its
also a pain in the $#@ to have to
worry about a semi-awake patient
when you are busy transfusing,
especially if you need to manage the
patients airway even just slightly

Controversial
Contraindications
3) c) If the surgery involves maneuvers that
can compromise respirations (position, high
level, pressure on diaphragm) it can be
enough to send your patient into respiratory
failure if their respiratory function is even
slightly compromised by your Regional
anesthetic (PLUS, it is very uncomfortable for
the patient to feel like they cant breathe;
youll need a lot of sedation and that will
probably only make the situation worse)

Neuraxial Blockade in the

Setting of Anticoagulants &
Antiplatelet Agents
1) Oral Anticoagulants (Coumadin): ANY
patient on Coumadin, even if given just a few
doses in-hospital, needs a PT AND INR prior
to surgery (and they need to be normal!!!)
Coumadin should be d/ced at best a week
and at a minimum 5 days prior to surgery
and an INR of >1.5 is a CONTRAINDICATION
to using a block; <1.5, proceed with caution
(use spinal rather than epidural)

Antiplatelet Drugs
2) ASA and other NSAIDs: By themselves do
not appear to increase the risk of spinal or
epidural hematomas in regional anesthesia.
However, if the patient is on chronic therapy
or has been taking them for more that 2
weeks, a PFT should be obtained prior to
performing a regional anesthetic. Daily baby
ASA is safe and can be continued throughout
surgery and post-op, but chronic NSAID
therapy should be d/ced at least 3 days prior
to surgery and usually 5-7 days is best

Antiplatelet Drugs
2) Plavix and other related drugs: These
drugs are very potent and are an ABSOLUTE
contraindication to regional anesthesia.
They need to be d/ced for AT LEAST 7 days
with Plavix, 14 days with Ticlid and 48 hours
with Rheopro. All patients on the above
medications need a PFT prior to performing
any regional anesthetic, even if they have
d/ced meds for the recommended time
periods or longer

Standard Heparin
3) Standard Heparin (unfractionated):
Minidose subQ heparin is NOT a
contraindication to neuraxial blockade. On
patients who are receiving Heparin infusion,
the Heparin needs to be d/ced for at least 4
hours prior to block and a normal PTT needs
to be documented prior to performing your
block. If the patient is currently on a Heparin
infusion immediately preoperatively, then a
regional anesthetic is CONTRAINDICATED

Antiplatelet Drugs
3) Standard Heparin (contd):
If an epidural cath is placed and then
the patient is heparinized, the cath
cannot be removed until the heparin is
d/ced for at least 4 hours and a normal
PTT is documented. Also, if bleeding is
encountered during the block
procedure, at least an hour should pass
before the patient is heparinized.

Low-Molecular Weight
Heparin
4) Lovenox: If blood or bleeding occurs during
your block, Lovenox administration should be
delayed for at least 24 hours post procedure.
If an epidural cath is in place, it should be
removed AT LEAST 2 hours prior to
administration of the first dose of Lovenox. If
given while a cath IS in place, it cannot be
removed for at least 10 hrs. following the last
dose, and the next dose cannot be given for
at least 2 hours AFTER removal of the cath

Fibrinolytic/Thrombolytic
Therapy
5) Fibrinolytic/Thrombolytic
Therapy: Is an ABSOLUTE
contraindication to regional
anesthesia and needs to be d/ced for
at least 3 days prior to performing a
block. COMPLETE clotting studies
need to be done and documented
NORMAL prior to initiating your block
(PT, PTT, INR, PFT, Platelet Count)

SHORT Break
Time
(stretch)

Complications

The complications of Epidural, Spinal

and Caudal anesthetics range from
bothersome to the crippling and lifethreatening
Broadly, the complications can be
thought of as resulting from
exaggerated physiologic side effects,
placement of the needle, and drug
toxicity

Complications

A very large study of regional

anesthetics from France provides an
indication of the relatively low
incidence of serious complications
In contrast, the ASA Closed Claim
project helps identify the most common
causes of LIABILITY claims involving
Anesthetic complications in the OR
setting

Complications

1)
2)

In a 20 year period (1980-1999)

regional anesthesia accounted for
18% of ALL liability claims. The
claims were broken down by:
Temporary or Non-disabling (11.5%)
Serious injuries (death 2.3%;
permanent nerve injury 1.8%;
permanent brain damage 1.4% and
other permanent injuries 0.72%)

Complications

Lumbar EPIDURAL anesthesia accounted for

42% of all cases
Spinal anesthesia accounted for 34% of all
cases
Caudal anesthesia was utilized in only 2% of
all cases
ALL types had their complications occur
mostly in Obstetric patients (this reflects the
higher percentage of use of regional
anesthesia in these patients; 68%)

Complications
In the French study, the percentages were
MUCH lower
Out of 40,640 patients who had SPINALS,
0.00006% suffered cardiac arrests,
0.0001% died, 0.00004% had permanent
nerve injury
Out of 30,413 patients who had EPIDURALS,
0.00009% had cardiac arrests, 0% died and
0.0001% suffered permanent nerve injury
(The French have to ALWAYS be better than the
Americans in everything!!!)

Exaggerated Physiologic
Side Effects

1)
2)
3)
4)
5)
6)
7)
8)

These are:
Hypotension
Bradycardia
High Neural Block
Total Spinal
Cardiac Arrest during Spinal
Urinary Retention
Nausea
Hypoventilation

Hypotension

Hypotension is estimated to occur in about

1/3 of patients receiving spinal anesthesia
and in about 1/5 of all patients receiving
epidurals
The hypotension results from sympathetic
nervous system blockade that:
a) Decreases venous return to the heart and
that decreases cardiac output
b) Decreases Systemic Vascular Resistance
(SVR)

Hypotension

Modest decreases in blood pressure are

most likely from a drop in SVR
Large drops in blood pressure are from
BOTH a drop in SVR & Cardiac Output
The degree of hypotension often parallels
the level of spinal anesthesia and the
intravascular fluid volume of the patient
With hypovolemia, the extent of
hypotension can be markedly increased

Hypotension - Treatment

Is treated physiologically by restoration

of venous return so as to increase
cardiac output
Head down position (restore volume)
Volume administration (increase preload)
Pharmacologic correction of decreased
SVR (Neo) and drop in cardiac output
(Ephedrine)

Hypotension-Treatment

BE CAREFUL not to OVER-hydrate

patients who may be at risk for heart
failure from fluid overload
These are elderly patients, patients
with ischemic heart disease or a
history of any type of valvular heart
disease, patients with a history of
Congestive Heart Failure
In these patients, a Neo drip may be
needed instead of very aggressive
hydration

Bradycardia

Occurs in 10-15% of patients receiving spinal

anesthesia
Risk increases with increasing level of
anesthesia
Caused by block of cardioaccelerator fibers
originating from T1-T4
Usually promptly responds to treatment with
Atropine 0.2-0.4mg
There are reported cases of sudden Asystole
in the absence of any obvious preventable
events
For Asystole, prompt intervention with
Epinephrine is usually necessary to correct
the problem

High Neural Blockade

1)
2)

3)

High levels of neural blockade can occur

readily with either spinal or epidural
anesthesia
Causes are usually:
Administration of an excessive dose
Failure to reduce standard dose in selected
patients (elderly, pregnant, obese or very
short patients)
Unusual sensitivity or spread of local
anesthetic

High Neural Blockade

Spinal anesthesia ascending into the

cervical levels causes SEVERE
hypotension, bradycardia (blockade of
cardiac accelerator fibers) and
respiratory insufficiency
Unconsciousness, apnea and
hypotension resulting from high levels
of spinal anesthesia are referred to as
a High Spinal or a Total Spinal

High Neural Blockade

A High Spinal or Total Spinal can also

occur following an attempted
epidural/caudal if there is inadvertent
intrathecal injection
Sustained severe hypotension with a
LOW block can also lead to apnea via
severe medullary hypoperfusion

High Neural Blockade

Symptoms of a High neural block

include dyspnea and numbness or
weakness in the upper extremities
Nausea w or w/o vomiting usually
occurs and precedes the development
of hypotension
This may continue to develop into
severe hypotension, bradycardia and
respiratory insufficiency or total apnea

High Neural Blockade

Treatment of a high block or total spinal

include supplemental oxygen and
maintaining an adequate airway (from
a simple chin lift to placement of an
ETT)
Treatment also involves support of
circulation with volume, head down
position and vasopressors (see
treatment of hypotension)

High Neural Blockade

If conventional methods do not work with

the hypotension, then an Epi drip and
boluses may be needed
Bradycardia should be treated promptly
with Atropine and/or Epi
If respiratory and hemodynamic control
can be maintained, surgery may proceed
If vital signs remain unstable despite
aggressive treatment, then surgery should
be cancelled and the patient sent to an
ICU bed as soon as they are stabilized

Cardiac Arrest

Large Prospective studies report a

relatively high incidence of cardiac
arrest in patients having a spinal
anesthetic (1:1500)
Many of the arrests were preceded by
episodes of sudden bradycardia and
occurred in young healthy patients with
a low resting heart rate preoperatively

Cardiac Arrest

A recent study recognized strong vagal

responses and decreased preload as key
factors in development of CA
To prevent this occurrence, any patient
with a low resting heart rate
preoperatively should be treated with
prophylactic volume expansion and
PROMPT treatment of bradycardia with
Atropine, pressors or Epi as needed

Urinary Retention

Spinal Anesthesia blocks the S2-S4 root

fibers decreasing urinary bladder tone and
inhibits the voiding reflex
This may require catheterization to relieve
distension
The bladder paralysis is time dependent
and as the LA wears off, the normal bladder
tone and voiding reflex should return
There are rare instances in which the LA has
worn off, yet the bladder still gets distended
and requires catheterization

Urinary Retention

These patients may have to be admitted

overnight and usually an indwelling foley
is placed until the bladder regains tone
No Out-patient receiving neuraxial block
should be discharged until the patient can
void voluntarily
Also, if bladder dysfunction persists even
after the block has worn off, this may be a
manifestation of serious neural injury
secondary to the performance of the block
At that point a Neurology Consultation
may be in order

Nausea

Nausea occurring shortly after

initiation of a spinal anesthetic must
alert the Anesthetist to the possible
presence of hypotension sufficient to
cause cerebral ischemia
Treatment of the hypotension should
also treat the nausea (see
Hypotension)

Nausea

Another cause of nausea during a

spinal anesthetic is a predominance
of parasympathetic stimulation of the
GI tract (Sympathetics are blocked)
Treatment with Atropine (0.2-0.4mg)
may be effective therapy (blocking
muscarinic effects)
Zofran or Anzimet may also be used
instead of Atropine

Hypoventilation

Exaggerated hypoventilation may

accompany IV administration of drugs
intended to produce sedation during the
planned procedure
It is believed to be from an enhanced effect
of the drugs due to the sympathetic nervous
system blockade
Vigilance and attention to your patient and
monitors will help you discover this rare
complication if it ever occurs

1)
2)
3)
4)
5)
6)
7)
8)
9)
10)

Complications Associated
with Needle or Catheter
Insertion
The following can be caused by needle or

catheter insertion:
Inadequate Anesthesia or Analgesia
Intravascular Injection
Subdural Injection
Backache
Postdural Puncture Headache
Neurological Injury/Transient Radicular Irritation
Spinal or Epidural Hematomas
Meningitis or Arachnoiditis
Epidural Abscess
Sheering of an Epidural Catheter

Inadequate Spinal
Anesthesia

All neuraxial blocks are blind techniques

and as such will always have a failure rate
associated with them
The failure rate is commonly inversely
proportional to the clinicians experience
Even with the endpoint of spinal anesthesia
being free flow of CSF, failure can still occur
secondary to needle movement during
injection, incomplete entry of needle
opening into the SAS, (aspirate before AND
after injection) or loss of potency of LA due
to age

Inadequate Epidural
Anesthesia

Unlike Spinal anesthesia with its

defined endpoint (clear flow of CSF),
Epidural anesthesia is dependent on
detection of a subjective LOR and
variable anatomy of the epidural
space and less predictable spread of
LA

Inadequate Epidural
Anesthesia

1)

2)

3)

Misplaced injections can occur in a number

of situations:
False LOR is obtained in soft, pliable spinal
ligaments found in young patients
Para-spinous muscle injections with a
misplaced off-center injection can simulate
LOR
Your injection can go subdural or
intravascular instead of into the epidural
space

Inadequate Epidural
Anesthesia
4) A unilateral block can occur if your catheter
has either exited the epidural space or
coursed laterally
5) Segmental sparring or Hot Spots can occur
as a result of septations or scar tissue from
previous epidurals
6) Patients may complain of visceral pain during
lower abdominal procedures. This is due to
high level innervation of certain visceral
structures and can usually be overcome by
pushing your level a little higher. Visceral
fibers that travel with the vagus nerve may
also be responsible for this, and only
supplemental sedation can be used to
overcome this

Intravascular Injection

Inadvertent intravascular injection of LA

can produce very high serum levels of
LAs very rapidly
High levels in the CNS can cause
seizures and unconsciousness
High levels in the Cardiovascular system
can cause hypotension, arrhythmias and
eventual cardiovascular collapse

Intravascular Injection

Because the dosage of anesthetic is so

much smaller with a spinal, these
complications rarely occur with a spinal
but are primarily seen with epidurals
and caudals
LA can be injected directly into a vein
by the needle or later through the
catheter that has migrated into a blood
vessel

Intravascular Injection

The incidence of intravascular

injection can be minimized by
carefully ASPIRATING the needle or
catheter BEFORE EVERY injection!!
Also, the incidence can be reduced
by the use of a test dose with Epi to
see if you get a sudden increase in
heart rate

Intravascular Injection

Severe side effects can also be

prevented by ALWAYS injecting meds
in increments of 3-5cc and waiting to
see if any side effects occur (ringing
in ears, metallic taste in mouth,
circumoral numbness,
lightheadedness, SUDDEN weakness
or numbness in legs)

Subdural Injection

The SUBDURAL space (different from

the Subarachnoid space) is a potential
space between the DURA and the
ARACHNOID and extends intracranially
so any LA injected into the subdural
space can produce much more serious
complications than a high epidural can
A subdural injection can mimic a Total
Spinal in its symptoms and
physiologic changes

Subdural Injection

As with inadvertent IV injection,

inadvertent subdural injection of LA during
an EPIDURAL can become a disaster if not
recognized in a timely fashion
The clinical presentation is similar to that
of a Total Spinal and the management is
similar as well
The exception is that the onset may be
delayed for 15-30 minutes due to lower
concentrations of agents used

Subdural Injection

Again, the incidence of this occurring

can be reduced by incremental dosing
and use of a test dose with epi
The symptoms will resemble those of
a subarachnoid injection of your
epidural anesthesia with sudden onset
of numbness and weakness of the
lower extremities

Backache

As a needle passes through the skin,

subq tissues, muscle and ligaments it
causes varying degrees of tissue trauma
A localized inflammatory response with
or w/o muscle spasm may be
responsible for the presentation of a
postop backache
The more difficult the procedure was will
also increase the chances of the patient
experiencing a postop backache

Backache

It should be noted that up to 25-30% of

patients receiving GA ALONE also
complain of a backache postop
If it does occur, the backache or
soreness is usually mild and self-limited
It can last for up to several weeks in
some cases depending again on how
much trauma was done during the
procedure

Backache

Treatment is usually initially with

Acetaminophen and warm then cold
compresses
If stronger treatment is needed, then
NSAIDs can be added to the regimen
If PO intake is not possible at that
point, Cox2 Inhibitors IV (Toradol) can
be given for 2-3 days then converted
to PO when possible

Backache

In RARE cases Narcotics can be prescribed

if pain is severe or unresponsive to other
conventional treatment methods
If the backache persists despite treatment
or gets worse, then this may be a sign of a
more serious complication occurring and a
Neurology consultation may be warranted
(abscess, hematoma, etc.)

Post-Dural Puncture
Headache

Characterized as frontal or occipital

Hallmark Feature: Worsens with
postural changes such as sitting or
standing
Supine, pain usually resolves when
lying FLAT
Occasionally accompanied by
Tinnitus and decreased hearing

Post-Dural Puncture
Headache

A headache w/o postural changes IS NOT

a Post-dural puncture headache
Caused by decreased CSF pressures and
resulting tension on meningeal vessels
and nerves as a result of leakage of CSF
through the needles hole in the dura
Incidence decreases with increasing age
and drops off rapidly over 55 years of
age

Post-Dural Puncture
Headache

1)

2)

3)

Incidence can be decreased by:

Using a rounded point needle (Sprotte
or Whitacre)
The point of the needle used to
puncture the dura is oriented PARALLEL
rather than perpendicular to the
meningeal fibers (running up and down)
Using a small gauge needle (25g)

Treatment of PDPH

Initially with bed rest, analgesics and

oral/IV hydration
If headache persists after 24-48 hours, it is
recommended to do a Blood Patch as the
next line of therapy
Blood patch is done by injecting 10-20cc of
the patients blood epidurally at or near the
same interspace that the original spinal
anesthetic or dural puncture was performed

Treatment of PDPH

Prompt relief of the headache occurs in

85% of patients that receive a blood
patch
Due to the blood Sealing the hole
and slowing or stopping the leak of CSF
Of those patients who do not respond
to the initial blood patch, 90% will
respond to a second blood patch
Most common side effects of blood
patch are backache and radicular pain;
usually resolves within 24 hours

Treatment of PDPH

An alternate treatment is administration

of IV Caffeine sodium benzoate (500mg)
It has been shown to be effective in
about 70% of patients with PDPH
A controversial treatment is to inject NS
or blood through an epidural catheter if
it had occurred as a result of an
epidural, as a prophylactic measure
before taking out the catheter
No study has been done that shows if
NS or blood via the catheter works or
not

Neurological Injury

Serious neurologic injury is a rare but

widely feared complication of epidural
and spinal anesthesia
Multiple large number studies have
shown that the incidence of neurologic
injury occurs between 0.03 and 0.1% of
all central neuraxial block patients
Of note is that in most of these series,
the block was not proven to be causative

Neurologic Injury

Persistent paresthesias and limited

motor weakness are the most common
injuries, although paraplegia and
diffuse injury to cauda equina roots
(cauda equina syndrome) do occur, but
rarely
There does seem to be a slightly
higher rate of injury associated with
Epidurals vs. Spinals and this is
thought to be due to the larger size of
the needle used in Epidurals

Neurologic Injury
Injury may result from:
a) Direct needle trauma to the spinal
cord or spinal nerves
b) Spinal cord ischemia

Neurological Injury

Spinal cord injury can be avoided by

performing your block below L1 in
adults and L3 in Pediatric patients
Also, any persistent parasthesia
during injection or catheter passage
should be dealt with by immediately
stopping what you are doing and
withdrawing either the needle of cath
a few cm and then try again

Neurological Injury

Direct injection into the spinal cord

can cause paraplegia
Damage to the Conus Medullaris may
cause isolated sacral dysfunction with
lower extremity muscle weakness
and loss of bowel or bladder function
Needles can cause direct physical
trauma to spinal nerve roots as well

Neurological Injury

Although most neurologic complications

resolve spontaneously, some become
permanent
Most permanent deficits have been
associated with parasthesias from
either needle or catheter that were not
dealt with appropriately (withdrawing
needle or catheter as soon as it is
established that the parasthesia is
persisting)

Neurological Injury

Some studies have suggested that

multiple attempts of a difficult block
raise the chance of needle trauma
significantly (Dont be a hero!! If you
cant get the block after 2-3 tries, call
for help and another pair of hands!!)

Neurological Injury: Spinal

Ischemia

Spinal cord Ischemia usually occurs as

a result of Global systemic hypotension
and with the additional pressure being
placed on the spinal cord by the
epidural anesthetic, a higher level of
pressure is needed to perfuse the
spinal cord as a result of the external
pressure
Treatment is prompt treatment of
hypotension

Neurological Injury:
Obstetrics
A few things to keep in mind when
dealing with Obstetric patients:
33% of Obstetric patients have
neurological injury W/O even receiving
a block; secondary to nerve injury or
sustained pressure on nerves during
normal or (more commonly) long
periods of labor and delivery

Neurological Injury:
Obstetrics

Postpartum deficits usually involve Lateral

Femoral Cutaneous neuropathy
(weakness of legs and pain in both inner
thighs), foot drop, and possibly paraplegia
Again, these injuries occur even without a
block, so if any of these types of injuries
are reported after a long labor with an
epidural, they are most commonly from
nerve trauma during delivery

Neurological Injury:
Obstetrics

Get a Neurology consultation ASAP just in

case, but the Neurologist will usually clear
your block of any blame once the symptoms
are disclosed and the patient is examined
In most cases these injuries are self-limiting
and will resolve within a week or two, so
reassure your patient that what they are
feeling is temporary and is secondary from
their labor and delivery and NOT your block
but dont forget, DOCUMENT, DOCUMENT,
DOCUMENT!!!

Neurological Injury:
Obstetrics

If, however, their symptoms persist longer

than a few weeks, the OB doc will probably
send the patient to a neurologist and if
there is the slightest chance that the
symptoms are from your block, believe me
the patient will get in touch with you so fast
it will make your head spin
When the smell of money is in the air,
people tend to work very quickly and
efficiently

Transient Radicular
Irritation

Transient Radicular Irritation of the

Lumbosacral nerves manifests as
moderate to severe pain in the lower
back, buttocks, and posterior thighs
Usually appears within 24 hours AFTER
complete recovery from a Spinal
anesthetic
The delayed onset of pain reflects the
development of inflammation and
irritation

Transient Radicular
Irritation

Full recovery usually occurs within 7 days

Bupivicaine and Tetracaine are associated
with a LOWER incidence of occurrence
Treatment revolves around the use of
NSAIDS to decrease inflammation
In rare cases, steroids may need to be
administered PO to decrease the
inflammatory response
Persistent pain may be due to infection or
abscess formation and then aggressive
treatment is necessary

Spinal or Epidural
Hematoma

Needle or catheter trauma to

epidural veins often causes minor
bleeding in the spinal canal that is
usually benign and self-limiting
Unfortunately, sometimes the
bleeding can lead to the formation of
a significant hematoma (spinal or
epidural)

Spinal/Epidural
Hematomas

The incidence of such hematomas has

been estimated to be about 1:150,000
for epidurals and 1:220,000 for spinal
anesthetics
The vast majority of reported cases
have occurred in patients with
abnormal coag numbers either
secondary to disease or pharmacologic
therapies

Spinal/Epidural
Hematomas

It should be noted that some hematomas

have been associated with REMOVAL of an
epidural catheter as well as insertion
The hematomas result in a mass effect on
the spinal cord with anywhere from mild to
severe symptoms
Unless the condition is diagnosed rapidly
and appropriate treatment is instituted as
soon as possible, permanent neurologic
injury can occur

Spinal/Epidural
Hematoma

Symptoms typically appear suddenly

and include sharp back pain and leg
pain with a progression to numbness,
motor weakness and sphincter
dysfunction
MRI or CT must be obtained as soon as
the possibility of a hematoma is
considered as well as a Neurology
consultation ASAP

Spinal/Epidural
Hematoma

In many cases good neurological recovery has

occurred in patients who have undergone
surgical decompression within 8-12 hours (and
needless to say that their anesthesia bill is
wiped clean and their #$@% is kissed
thoroughly)
To prevent its occurrence, Neuraxial anesthesia
should be avoided in any patient with
coagulopathies, significant thrombocytopenia
(<80-100,000), platelet dysfunction or those
who have received fibrinolytic/thrombolytic
therapy within 5 days of possibly receiving a
block

Meningitis &
Arachnoiditis

Infection of the Subarachnoid or Epidural

space can follow neuraxial blocks as the
result of contamination of the equipment
or injected solutions or as a result of
organisms tracked in from the skin
Indwelling catheters can become
infected and track deep along the
catheters path
Although possible, thankfully these are
rare complications

Meningitis &
Arachnoiditis

Another rarely reported complication is

Arachnoiditis
It can be either infectious or non-infectious
Clinically, signs are pain and other
neurological symptoms and an MRI/CT
scan will show CLUMPING of nerve roots
It is often seen following epidural steroid
injections but most commonly seen after
spinal surgery or trauma

Epidural Abscess

Epidural abscess (EA) is a rare but

devastating complication of neuraxial
anesthesia
The incidence varies widely from
1:6500 to 1:500,000 epidurals
depending on which study you look at
EA can even occur in patients who
never received a neuraxial block
(systemic spread)

Epidural Abscess

Most anesthesia cases are associated

with the use of an Epidural catheter
A hallmark of EA is the long delay in
appearance of symptoms; one study
showed a mean period of 5 days
from insertion to symptoms
Sometimes presentation can be
delayed for weeks

Epidural Abscess

Initially symptoms usually appear as back

or vertebral pain which worsens during
percussion over the spine
Next, nerve root or radicular pain usually
develops
This is usually followed by motor and
sensory deficits and sphincter
dysfunction
The final stage is usually paraplegia or
paralysis

Epidural Abscess

Prognosis is associated with the

degree of neurological dysfunction at
the time of diagnosis
Back pain and fever should alert the
clinician to the possibility of an EA
Once EA is suspected, if a catheter is
in place it needs to be removed ASAP
and MRI/CT scan needs to be
obtained right away

Epidural Abscess

The catheter tip should be cultured and

the insertion hole should be expressed to
see if any pus is present. This should be
cultured as well
IV antibiotic therapy should be instituted
after cultures are obtained and an
Infectious Disease consult ordered at
once
Neurosurgical consultation should also
be obtained ASAP

Epidural Abscess

Treatment usually involves surgical

drainage and decompression especially if
neurologic deficits exist
There are very few reports of patients
recovering by the use of antibiotics alone
Measures to prevent it include minimal
catheter manipulation and removal of
any catheter after a maximum of 96
hours in place

Sheering of an Epidural
Catheter

This is always a risk with any catheter

through needle technique
It can happen especially if the
epidural catheter is pulled BACK
through the needle after its insertion
If for some reason a catheter gets
stuck during insertion then the
catheter and needle must be
withdrawn together as a unit and a
new catheter placed from the start

Sheering of an Epidural
Catheter

If a catheter breaks of or sheers off

deep within the epidural space, experts
suggest leaving it alone and carefully
observing the patient
If the breakage occurs in the subQ
tissue, particularly if part of the
catheter is visible, it should be removed
right away either manually or surgically

Sheering of an Epidural
Catheter

In studies following patients with

sheered catheters in place, long term
complications are rare and most can
continue on without any complications
or problems
However, in a small number of patients,
the catheter causes an immune reaction
that can mimic an Epidural Abscess and
then has to be removed surgically

Sheered Catheter

Basically, if it happens, get a baseline

Neurologic Consultation which will probably
include an MRI/CT Scan and INFORM the
patient of the complication. A neurosurgical
consult isnt a bad idea either. DOCUMENT,
DOCUMENT, DOCUMENT
Tell the patient that the vast majority of the
people that this happens to go on and
never have a problem for the rest of their
lives BUT ALSO tell them that a very small
percentage DO develop symptoms that may
need further medical attention

Sheered Catheter

Tell them the symptoms that they may

feel can range from back pain to having
weakness or numbness in their legs and
that if any symptoms develop that
persist for longer than 2-3 days, to call
immediately and NOT to delay calling
Give them a phone number to call that
WILL be available even if you are not!!

Missing Tip

Just as an aside that is semi-related to a

Sheered Cath, whenever you are called to
REMOVE an epidural catheter, ALWAYS
look at the tip when it is removed and
DOCUMENT that the tip was seen
The tip is a THICK line that makes the tip
of the catheter black, so always make sure
you see it and if you dont, then
DOCUMENT and contact the person who
put it in and SAVE, SAVE, SAVE the cath in
a bag or a glove to show the person who
put it in because they probably wont
believe you when you tell them

Complications Associated
with Drug Toxicity

1)
2)
3)

There are three different clinical

situations that can arise from direct
toxicity of the LAs:
Systemic Toxicity
Transient Neurological Symptoms
Lidocaine Neurotoxicity (Cauda
Equina Syndrome)

Systemic Toxicity

Systemic toxicity occurs when there is

absorption of excessive amounts of LAs
which produces high, toxic serum levels
Excessive absorption from epidural or
caudal blocks is very rare, especially if
the dose used is within the
recommended guidelines of dosage per
kilogram
It is much more commonly caused by
direct intravascular injection (which was
previously discussed)

Transient Neurological
Symptoms

Transient Neurological Symptoms was

first described in 1993
It is also referred to as Transient
Radicular Irritation and is characterized
by back pain radiating to the legs W/O
sensory or motor deficit
The symptoms characteristically occur
AFTER the block has worn off and
resolves spontaneously within a few
days

Transient Neurological
Symptoms

It is most commonly associated with

hyperbaric Lidocaine (11.9%),
Tetracaine ( 1.6%), Bupivicaine ( 1.3%)
There are also case reports of TNS
following epidural anesthesia
The incidence is highest among
outpatients (early ambulation?) after
surgery in the lithotomy position and
lowest in inpatients done in positions
other than lithotomy

Transient Neurological
Symptoms

The pathogenesis of TNS is assumed to be

due to concentration-dependent
neurotoxicity of the LAs
Epidural Abscess must be considered if
symptoms progress from just pain to other
neurologic deficits
NSAIDS or Acetaminophen can be used for
the duration of symptoms, but if they fail
to resolve in a few days, a Neurology
consultation is warranted with a careful
physical exam performed

Cauda Equina Syndrome

Cauda Equina Syndrome (CES) is

associated with the use of CONTINUOUS
Spinal catheters and Lidocaine 5%
CES is characterized by bowel and
bladder dysfunction together with
evidence of multiple nerve root injury of
the lower extremities
It can manifest as both motor and
sensory deficits

Cauda Equina Syndrome

The patient may have significant pain

in the distribution of individual nerve
roots or a generalized pain of both
lower extremities
The cause seems to be maldistribution
of hyperbaric solutions of lidocaine
with a higher concentration of Lido 5%
coming in contact with particular
nerves and causing a toxic reaction
between the LA and the nerve root(s)

Cauda Equina Syndrome

The incidence is highest in cases that

utilize Spinal Catheters and Lido 5%,
next is Single shot spinals with
multiple LAs, then comes Epidurals
It is a very rare complication and
seems to occur in this order of LAs:
Lidocaine = Tetracaine > Bupivicaine
> Ropivicaine

Conclusion

You can see that the performance of

neuraxial blockades have quite a few
complications that can be associated
with their use
You must be familiar with them all,
regardless of how rare a particular
side effect or complication may occur

Conclusion

Again, even during a seemingly

uneventful block, keep thinking What
if? because one day your What
if? will turn into an actual
complication and the more you know
and plan, the better prepared you will
be to deal with whatever may come up
Remember to always stay one step
ahead and you can keep yourself AND
your patient out of trouble