ADDIS ABABA UNIVERSITY

 
SCHOOL OF ANESTHESIA

COMPLICATION OF NEURAXIAL ANESTHESIA AND THEIR

MANAGMENT

PREPARED BY Liya Yohannes

 
ADVISOR Instructor Tegegn Tesema

MAY 2014
 OBJECTIVE

At the end of this session you will be able to:-

Define neuraxial anesthesia

Explain complications associated with exaggerated physiological response to spinal

injection

Explain complications associated with Techniques or spinal Needle/Catheter Insertion

Explain complications associated with drug toxicity

Identify neuraxial anesthesia complications on time

Manage neuraxial complications appropriately

Cooperate with the patient and staff for the safety of the patient
OUTLINE

 Introduction
 Neuraxial anesthesia mechanism of action
 Complication of neuraxial block and their management
 Complications associated with exaggerated physiologic responses
 Complications Associated with Techniques or Needle/Catheter Insertion
 Complications Associated with Drug Toxicity
 Summary
 References
 INTRODUCTION

 NEURAXIAL ANESTHESIA is medication administered in to the epidural

space or spinal canal to block sensation of pain.

 It includes the use of spinal, epidural and caudal blocks.

 Neuraxial anesthesia is an effective method of producing analgesia, anesthesia,

and neuromuscular paralysis.

 These central blocks were widely used prior to the 1940s until increasing
reports of permanent neurological injury appeared.

 However, a large-scale epidemiological study conducted in the 1950s indicated

that complications were rare when these blocks were performed skillfully with
attention to aseptic technique.
 MECHANISM OF ACTION

 The principal site of action for neuraxial blockade is the nerve root.

 Local anesthetic is injected into CSF or the epidural space and bathes the
nerve root in the subarachnoid space or epidural space, respectively.

 Direct injection of local anesthetic into CSF allows a relatively small dose and
volume to achieve dense sensory and motor blockade.
 COMPLICATIONS OF NEURAXIAL BLOCKS AND THEIR MANAGNENT

 The complications of Epidural, Spinal and Caudal anesthetics range from

bothersome to the crippling and life-threatening conditions.

 Broadly, the complications can be thought of as resulting from:-

1. exaggerated physiologic side effects,

2. placement of the needle and

3. drug toxicity.
1. COMPLICATIONS ASSOCIATED WITH ADVERSE/EXAGGERATED
PHYSIOLOGICAL RESPONSES

1.1 Hypotension

1.2 Bradycardia and Asystole

1.3 Nausea and vomiting

1.4 Total Spinal/high spinal

1.5 Hypoventilation

1.6 Body temperature

1.7 Urinary Retention

 1.1 HYPOTENSION

 Particularly in elderly patient and those who have not been

adequately preloaded with fluids.

 Hypotension is estimated to occur in about 1/3 of patients receiving

spinal anesthesia and in about 1/5 of all patients receiving epidural.

 Usually develops in the first 15 to 20 minutes.

 HYPOTENSION CONT.……

 Causes are
 Vasodilatation and
 a functional decrease in the effective circulating volume from
sympathectomy

 Warning signs are pallor, sweating, nausea or feeling generally unwell. 

 To decrease the incidence of hypotension rehydrating our patient with 500-

1000 ml of crystalloid before 20 to 30 minute performing the block is helpful.
 HYPOTENSION CONT.……

 Treatment

1. Increasing total circulating blood volume (by the administration of

intravenous fluids) and, if the pulse is slow, give atropine 0.5 to 1 mg

intravenously.

2. A simple and effective way of rapidly increasing the patient's circulating

volume is by elevating their legs.

3. All hypotensive patients should be given oxygen by mask until the blood

pressure is restored.
HYPOTENSION CONT.……

4. Vasoconstrictors should be given immediately if the hypotension is

severe, and to patients not responding to fluid therapy.

 Ephedrine causes peripheral blood vessels to constrict and raises the

cardiac output by increasing the heart rate and the force of myocardial
contraction.

 2.5-6mg titrated dose against the blood pressure. (10 minutes )

 Epinephrine/Adrenaline
 give increments of 50mcg repeating as necessary.
 1.2 Bradycardia and Asystole

 The heart rate does not change significantly in most patients(10-15% of patients receiving spinal anesthesia significant

bradycardia.)

 Onset occurred 5 minutes to 3 hours after initiation of the block.

 Speculated mechanisms for this bradycardia include

block of cardioaccelerator fibers originating from T1 through T4

decreased venous return (Bezold-Jarisch reflex).

 
 BRADYCARDIA AND ASYSTOLE CONT.……

 Treatment consists :-

 pharmacologic treatment of bradycardia (ephedrine 5 to 50 mg IV;

atropine 0.4 to 1.0 mg IV ,epinephrine 0.05 to 0.25 mg IV.)

 rapid administration of fluids

 physical maneuvers ( leg up position.)

 BRADYCARDIA AND ASYSTOLE CONT.……

 during asystole cardiopulmonary resuscitation was initiated and

resuscitation drug epinephrine can be used(1.0 mg IV).

 It may be prudent to prophylactically treat bradycardia (HR <50),

particularly in patients with a strong resting vagal tone in whom

enhanced vagal activity can lead to cardiac arrest.

 1.3 NAUSEA AND VOMITING

 Nausea and vomiting occur after spinal anesthesia approximately 20% of the
time, usually the result of :-
 hypotension or
 unopposed vagal stimulation (Sphincters are relaxed, secretions
increase and peristalsis is normally active.)

 Risk factors include blocks higher than T5, hypotension, opioid

administration, and a history of motion sickness.

 Treatment
 Treat the cause(The main cause of nausea is hypotension.)
 Re-assurance.
 NAUSEA AND VOMITING CONT.……

 Encourage deep breathing.

 Metoclopramide 10 mg IV or IM.

 Ondansetron 4 mg. IV.

 To prevent PONV plan may start with the

 identification of patients at risk and
 administration of prophylactic antiemetics.  

 Intraoperatively, avoidance of hypotension, use of vasopressors with known

antiemetic properties such as ephedrine, and adequate hydration may be
helpful.
 NAUSEA AND VOMITING CONT.……

 Perioperative supplemental oxygen may relieve the nausea associated with

brainstem ischemia due to profound hypotension. 

 Additives to local anesthetics, such as neostigmine, should be reserved for

those patients with clear indications.  

 Similarly, the choice of intrathecal and epidural narcotics should be made on

the basis of the side effect profile; opioids such as fentanyl and sufentanil carry
lower than morphine and meperidine.
 1.4 HIGH SPINAL/ TOTAL SPINAL

 High levels of neural blockade can occur readily following spinal anesthesia.

 The causes are :-

 administering an excessive dose,

 failure to reduce standard doses in selected patients

 unusual sensitivity or spread of LA.

 positioning error

 Inadvertent spinal anesthesia when attempting epidural anesthesia (most

frequent cause!).
 HIGH SPINAL/ TOTAL SPINAL CONT.……

 Spinal anesthesia ascending into the cervical levels causes severe hypotension,
bradycardia, and respiratory insufficiency.

 Unconsciousness, apnea, and hypotension resulting from high levels of spinal

anesthesia are referred to as a “ high spinal " or “ total spinal."

 Treatment of high spinal is supportive until the spinal wears off.

 HIGH SPINAL/ TOTAL SPINAL CONT.……

 Once it is recognized
 patients should be reassured
 oxygen supplementation may need to be increased
 bradycardia and hypotension should be corrected.

 If respiratory insufficiency becomes evident, in addition to supplemental

oxygen :-

 assisted ventilation

 intubation

 mechanical ventilation may be necessary.

 1.5 RESPIRATORY ARREST

 Decreases in vital capacity or hypoventilation can occur if the motor block

extends into the upper thoracic and cervical dermatomes.

 The most likely cause of transient respiratory arrest during high spinal
anesthesia is ischemia of medullary respiratory neurons.

 The character of spontaneous respirations serves as a valuable indication of

the adequacy of medullary blood flow during high spinal anesthesia.
 RESPIRATORY ARREST CONT.……

 Therefore It is advisable to let patients breathe spontaneously during high

spinal anesthesia rather than to control ventilation.

 Exaggerated hypoventilation may accompany IV administration of drugs

intended to produce sedation during the planned procedure.

 Vigilance and attention to your patient and monitors will help you discover this
rare complication if it ever occurs.
 1.6 BODY TEMPERATURE

 Like general anesthesia, central neuraxial anesthesia is also associated

with significant changes in body temperature and impairment of
temperature homeostasis.  

 The decrease in body temperature associated with the onset of central

neuraxial block has three reported mechanisms: -

1. Loss of the patient's thermoregulatory capability, with impaired

shivering and loss of the ability to sense cold temperatures,

2. Sympathectomy-induced peripheral vasodilation, resulting in

admixing of peripheral (cool) with core (warm) blood
 BODY TEMPERATURE CONT.……

3.Loss of tissue heat below the level of sympathectomy due to vasodilation

 Maintenance of temperature homeostasis perioperatively has paramount

importance because perioperative hypothermia may be associated with
significant morbidity .

 Treatment

 Active rewarming with forced air blankets ,

 minimizing body surface area exposure, and

 warming of intravenous fluids.

 1.7 URINARY RETENTION

 Local anesthetic block of S2-S4 root fibers decreases urinary bladder tone and
inhibits the voiding reflex, and also Neuraxial opioids can interfere with normal
voiding.

 These effects are more common in elderly men and those with a history of
benign prostatic hypertrophy.

 Patients complain of severe lower abdominal and back pain.

 Urinary bladder catheterization should be used to relieve distension If a

catheter is not present postoperatively, close observation for voiding is
necessary.
2. COMPLICATIONS ASSOCIATED WITH TECHNIQUES OR NEEDLE/CATHETER INSERTION

2.1 Inadequate Anesthesia or Analgesia

2.2 Intravascular Injection

2.3 Subdural Injection
2.4 Backache
2.5 Postdural Puncture Headache
2.6 Neurological Injury
2.7 Spinal or Epidural Hematomas
2.8 Meningitis
2.9 Epidural Abscess
2.10 Sheering of an Epidural Catheter
2.1 INADEQUATE ANESTHESIA OR ANALGESIA

 The failure rate is commonly inversely proportional to the anesthetist’s

experience.

 Even with the endpoint of spinal anesthesia being free flow of CSF, failure can
still occur secondary to :-

 needle movement

 incomplete entry of needle opening into the SAS

 loss of potency of LA due Outdated or improperly stored local

anesthetics

 Inadequate dose
 INADEQUATE ANESTHESIA OR ANALGESIA CONT.……

 Epidural anesthesia is dependent on detection of a subjective LOR and variable

anatomy of the epidural space and less predictable spread of LA and technique can

lead to false positives.

 Also not waiting long enough to let it work is another cause.

 Treatment

Wait for 10 min, if not try again

Must always be prepared to convert to general anesthesia or supplement.

  
 2.2 INTRAVASCULAR INJECTION

 The risk of serious complications related to an intravascular injection, when

performing a spinal anesthetic, is almost non-existent.

 Factors affect the potential response to large doses of local anesthetics and
include :-
 Type of local anesthetic (chloroprocaine< lidocaine< levobupivacaine <
ropivacaine < bupivacaine ) ,
 Rate of injection.

 Early symptoms include an increase in heart rate (if using an epinephrine

containing solution), tinnitus, a funny or metallic taste, and subjective changes in
mental status.
 INTRAVASCULAR INJECTION CONT.……

 If the patient experiences early symptoms, stop the administration of local

anesthetics and anticipate impending complications such as seizures,
hypotension, and cardiac arrest.

 The use of lipids in the treatment of local anesthetic toxicity has shown promise.
There are currently no established methods and research continues.

 Prepare the appropriate medications and equipment. Next, re-evaluate the

placement. If there is any doubt about proper placement, simply remove the
epidural catheter and once symptoms have abated, replace the catheter.
 INTRAVASCULAR INJECTION CONT.……

 Lipid Rescue Protocol (Experimental)

 20% Intralipid ,1.5 mg/kg initial bolus,0.25 mg/kg/min infusion for 30-60
minutes, bolus may be repeated 1-2 times for persistent asystole, May
increase infusion rate if blood pressure decreases.

 Prevention includes the:-

 use of a test dose prior to the injection of local anesthetic,
 careful aspiration prior to injection,
 incremental dosing, and
 vigilant monitoring for early signs and symptoms of an intravascular
injection.
 2.3 SUBDURAL INJECTION

 The subdural space is a potential space found between the dura and arachnoid
mater. It contains a small amount of serous fluid and extends intracranially.

 Local anesthetics can travel higher in the subdural space than in the epidural
space.

 Treatment is the same as with high neuraxial blockade (i.e. supportive

measures such as intubation, mechanical ventilation, and cardiovascular
support).

 Prevention is more difficult since aspiration will generally be negative.

However, with slow and incremental dosing, a higher and faster progression of
the anesthetic will be noted than one normally expects.
 2.4 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 also increase the chances of the patient
experiencing a postop 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 in

some cases.
 BACKACHE CONT.……

 Treatment is usually initially with Acetaminophen and warm then cold

compresses.

 If stronger treatment is needed, then NSAID’s can be added to the regimen.

 In RARE cases Narcotics can be prescribed if pain is severe or

unresponsive to other 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.)
 2.5 POST DURAL PUNCTURES HEADACHE

 The most widely accepted explanation for the cause of head ache is that
the leakage of CSF through the hole in the dura mater lowers the pressure
in the subarachnoid space.

 Loss of CSF causes downward displacement of the brain and resultant

stretch on sensitive supporting structures.

 Pain also results from distention of the blood vessels,which must

compensate for the loss of CSF because of the fixed volume of the skull.

 Features of a spinal headache occur within 12- 48 hours.

 POST DURAL PUNCTURES HEADACHE CONT.……

 The spinal headache is different from any the patient has experienced before:-

 It is worse on sitting up. It is relieved by lying down.

 External stimuli, such as light and noise, make the headache worse.

 The headache is mainly at the back of the head (occipital) and is

associated with pain down the neck.

 It is relieved by increasing abdominal pressure.

 POST DURAL PUNCTURES HEADACHE CONT.……

 The incidence of spinal headaches is related to the size of the needle.

 Treatment

 Reassurance

 Frequent long drinks

 Sedation and analgesia

 Caffeine (It blocks adenosine receptors in the central nervous system

and causes cerebral arterial vasoconstriction, counteracting the reactive

cerebral vascular dilatation. )

 POST DURAL PUNCTURES HEADACHE CONT.……

 Epidural blood patch

 Is indicated if it persists 24hr following other treatment .

 Performed by placing the needle in to the epidural space in the vicinity of

previous dural puncture and aseptically injecting 10-20ml of autologous

blood.

 The procedure is effective 90-95% but may be repeated if relief has not

been obtained within 24hr.

 Failure of two epidural patches is due to improper diagnosis.

 POST DURAL PUNCTURES HEADACHE CONT.……

 Complications are minimal but low back pain and nuchal discomfort are most
common ,usually resolved with in 24 hr. and treated with analgesics.

 Prevention

 Use a fine needle.

 Make sure the fibres of the dura mater are divided and not cut by adjusting

the bevel of the needle.

 Avoid multiple punctures.

 Nurse the patient flat for 6 hours post-operatively.

 Avoid coughing and straining post-operatively.

 2.6 NEUROLOGICAL INJURY

 Are extremely rare this is because of the

 Use of disposable spinal kits

 Small doses and relative safety of LA employed

 Postoperative peripheral neuropathies can be due to direct physical

trauma to nerve roots, Although most resolve spontaneously, some are

permanent.
 NEUROLOGICAL INJURY CONT.……

 Some of these deficits have been associated with paresthesia from the needle or
catheter or with complaints of pain during injection.

 Multiple attempts during a technically difficult block are also a risk factor.

 Direct injection into the spinal cord can cause paraplegia.

 Persistent paresthesias and limited motor weakness are the most common
injuries.
 NEUROLOGICAL INJURY CONT.……

 Causes

 spinal cord ischemia

 Needle trauma, subarachnoid hemorrhage

 Chemical contamination of LA

 Toxicity of LA solution themselves

 Spinal cord injury can be avoided by performing your block below L1 in

adults and L3 in Pediatric patients.
 NEUROLOGICAL INJURY CONT.……

 In general to reduce neurologic complications after spinal anesthesia:-

 Maintain strict sterility throughout the spinal block procedure.

 Ensure coagulation parameters are within normal limits.

 Use the lowest efficient dose of local anesthetic solution.

 Reevaluate after incomplete neural blockade prior to performing

another spinal anesthetic.

 Avoid large volumes and repeated injections of hyperbaric lidocaine.

 Never use preservative-containing solutions in the subarachnoid space.

 2.7 SPINAL OR EPIDURAL HEMATOMAS

 Needle or catheter trauma to epidural veins often causes minor bleeding in the spinal
canal, although this is usually benign and self-limiting.

 A clinically significant spinal hematoma can occur following spinal or epidural

anesthesia, particularly in the presence of abnormal coagulation or bleeding disorder.

 Hemorrhage into the spinal canal most commonly occurs in the epidural space because
of the prominent epidural venous plexus.

 The pathological insult to the spinal cord and nerves is due to a mass effect
compressing neural tissue and causing direct pressure injury and ischemia.
 SPINAL OR EPIDURAL HEMATOMAS CONT.……

 Symptoms include sharp back and leg pain with a progression to numbness and
motor weakness and/or sphincter dysfunction.

 Neuraxial anesthesia is best avoided in patients with coagulopathy, significant

thrombocytopenia(<80-100,000 cell/mm3), platelet dysfunction, or those who
have received fibrinolytic/thrombolytic therapy.

 The need for rapid diagnosis and intervention is paramount if permanent

neurological sequelae are to be avoided.

 When hematoma is suspected, neurological imaging (MRI or CT) must be

obtained immediately and neurosurgical consultation should be requested.
 2.8 MENINGITIS

 Meningitis is a rare complication(1:50,000 SA Vs 1:90,000 EA)

 most cases of post neuraxial blockade bacterial meningitis are due to:-
 contamination of the puncture site by aerosolized mouth particles.
 skin bacteria and from endogenous sites of infection.

 The presentation of meningitis may mimic a post dural puncture

headache.
 MENINGITIS CONT.……

 Signs and symptoms of meningitis may include headache, neck pain, fever, and
alteration in the level of consciousness.

 To reduce this neurologic complications after spinal anesthesia, strict sterility

is maintained throughout the spinal block procedure.
 2.9 EPIDURAL ABSCESS

 Epidural abscess is a rare(epidural catheters) but potentially devastating

complication of neuraxial anesthesia.

 Thereare four classic clinical stages of EA, although progression and time course can
vary :-

1.Initially, symptoms include back or vertebral pain that is intensified by percussion

over the spine.

2.Second, nerve root or radicular pain develops.

3.The third stage is marked by motor and/or sensory deficits or sphincter dysfunction.

4.Paraplegia or paralysis marks the fourth stage.

 EPIDURAL ABSCESS CONT.……

 Back pain and fever after epidural anesthesia should alert the anesthetist to
consider EA.

 Once EA is suspected, the catheter should be removed (if still present) and the
tip cultured.

 MRI or CT scanning should be performed to confirm or rule out the diagnosis.

 Treatment usually involves surgical drainage and decompression especially if

neurologic deficits exist
 EPIDURAL ABSCESS CONT.……

 There are a few reports of patients with no neurological signs being treated
with antibiotics alone.

 Neurosurgical consultation should also be obtained ASAP

 Suggested strategies for guarding against the occurrence of EA include:-

 minimizing catheter manipulations

 removing an epidural catheter after 96 h or at least changing the

catheter, filter, and solution every 96 h.

 2.10 SHEERING OF AN EPIDURAL CATHETER

 This is always a risk with any catheter through needle technique.

 Never attempt to withdraw an epidural catheter back through the needle, Pull
both the needle and catheter out at the same time.

 If the epidural catheter sheers or breaks off in the epidural space, it should be
left in place and observe the patient for complications.

 If the catheter breaks outside of the epidural space, in superficial tissue, it

should be surgically removed.
 SHEERING OF AN EPIDURAL CATHETER CONT.……

 Patients with sheered catheters in place, long term complications are rare and
most can continue on without any complications or problems.

 Basically, if it happens, get a baseline Neurologic Consultation which will

probably include an MRI/CT Scan and INFORM the patient of the
complication. But don’t forget to 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.

 Tell them the symptoms that they may feel can range from back pain to having
weakness or numbness in their legs.
3. COMPLICATIONS ASSOCIATED WITH DRUG TOXICITY

3.1 Systemic Toxicity

3.2 Transient Neurological Symptoms

3.3 Lidocaine Neurotoxicity (Cauda Equina Syndrome)

3.4 Allergy
 3.1 SYSTEMIC TOXICITY

 Systemic toxicity occurs when there is absorption of excessive amounts of LA’s

which produces high, toxic serum levels.

 It is much more commonly caused by direct intravascular injection

 Treatment of systemic toxicity is primarily supportive.

 Injection of local anesthetic should be stopped.

 Oxygenation and ventilation should be maintained.

 SYSTEMIC TOXICITY CONT.……

 If needed, the patient's trachea should be intubated and positive pressure

ventilation instituted.

 Seizures can increase body metabolism and cause hypoxemia, hypercarbia, and
acidosis.  

 Pharmacologic treatment to terminate seizures may be needed if oxygenation and

ventilation cannot be maintained. Intravenous administration of thiopental (50 to
100 mg), midazolam (2 to 5 mg), and propofol (1 mg/kg) can terminate seizures.

 Succinylcholine (50 mg) can terminate muscular activity from seizures and
facilitate ventilation and oxygenation.
 
 3.2 TRANSIENT NEUROLOGICAL SYMPTOMS

 First described in 1993, transient neurological symptoms (TNS), also referred to as

transient radicular irritation.

 Are characterized by back pain radiating to the legs without sensory or motor
deficits.

 Resolves spontaneously within 72 hours or several days.

 It is most commonly associated with hyperbaric lidocaine (incidence up to 11.9%),

but has also been reported with tetracaine (1.6%), bupivacaine (1.3%),
mepivacaine, prilocaine, procaine, and subarachnoid ropivacaine.
 TRANSIENT NEUROLOGICAL SYMPTOMS CONT.……

 Increased risk of TNS is associated with lidocaine, the lithotomy position, and
ambulatory anesthesia.

 The pathogenesis of TNS is believed to represent concentration-dependent

neurotoxicity of local anesthetics.

 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 examination performed.
 3.3 LIDOCAINE NEUROTOXICITY (CAUDA EQUINA SYNDROME)

 It is a very rare complication (Lidocaine = Tetracaine > Bupivicaine >

Ropivicaine.)

 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.

 Other risk factors include

 repeated dosing of local anesthetic solution through continuous spinal
catheters and possibly multiple single-injection spinal anesthetics.
 LIDOCAINE NEUROTOXICITY (CAUDA EQUINA SYNDROME) CONT.……

 CES is characterized by bowel and bladder dysfunction together with paresis of

the legs.

 The patient may have significant pain in the distribution of individual nerve
roots or a generalized pain of both lower extremities.

 Current suggestions for prevention of CES

 S.A include aspiration of CSF before and after injection

 Limiting the amount of L.A given in the subarachnoid space.

 3.4 ALLERGY

 Allergic reactions to local anesthetics are rare and Esters are more likely to
cause allergic rxn.

 Allergic reactions to amides are extremely rare and are probably related to the
preservative (methylparaben) and not the amide itself.

 Most reactions are related to vagal reactions, toxicity of local anesthetics,

effects of epinephrine such as tachycardia, flushing, and tachypnea.

 Local hypersensitivity reactions may produce local erythema, edema, or

dermatitis.

 Skin testing with intradermal injections of preservative-free local anesthetics

uses to determine tolerance to local anesthetic.
 ALLERGY CONT.……

 Treatment includes the following: -

 Stop the administration of the suspected medication

 Administer 100% oxygen and consider intubation

 Epinephrine (0.01-0.5 mg IV or IM)

 Administer fluids rapidly to combat the hypovolemia and shock

 Hydrocortisone up to 200 mg IV or alternatively

 methylprednisolone in a dose of 1-2 mg/kg

 SUMMARY

 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.

 Prior to ANY Spinal or Epidural anesthetic, a CAREFUL examination of the back

should Be included.(Surgical Scars, Scoliosis, and Skin lesions.)

 coagulation studies and platelet count should be checked when clinical history
suggests the possibility of a bleeding diathesis.
 SUMMARY CONT.……

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

 Always remember Knowledge, preparation, and anticipation can help reduce

complications and if it already happen we can avoid further damage and
complications.

 Treat hypotension early and do not let it progress to cardiac arrest.

 To prevent our patient from infections always keep strict aseptic technique.
SUMMARY CONT.……

 The main point is vigilance and early treatment!

 REFERENCE

1. Admir Hdzic (2007) Textbook of Regional Anesthesia and Acute Pain

2. ManagementBarash, Paul G.; Cullen, Bruce F.; Stoelting, Robert K.; Cahalan, Michael

K.; Stock, M. Christine (2009) Clinical Anesthesia, 6th Edition

3. Edward Morgan, Jr., Maged S. Mikhail, Michael J. Murray Clinical Anesthesiology, 4th

Edition

4. D.Miller (2005) Miller's Anesthesia - 7th Ed

5. Vincent Conte. Regional anesthetic complications(fiu)

6. Daniel D.Moss , Developing countries regional anesthesia lecture serious

7. Lucille Bartholomeusz(1986)safe anesthesia third edition updated and revised byJean

Lees 2006Ronald
THANK YOU ALL!