Complications in obstetricanesthesia

Complications in obstetricanesthesia

C.MelloniC.Melloni

Servizio di Anestesia e RianimazioneServizio di Anestesia e Rianimazione

Ospedale di Faenza(RA)Ospedale di Faenza(RA)

Report on Confidential enquiries into maternal deaths in England and Wales 1970-1996

0

5

10

15

20

25

30

1970-72 73-75 76-78 79-81 82-84 85-87 88-90 91-93 94-96

emb.polm

ipertens

anest

emb.fluido amniotico

aborto

gravid.ectopica

emorragia

sepsi

rottura utero

altre cause dirette

Entrata in vigore della nuova classificazione

Maternal deaths attributed to anesthesia

0

2

4

6

8

10

12

14

1970-72

73-75 76-78 79-81 82-84 85-87 88-90 91-93 94-96

Maternal deaths related to anesthesia per million of pregnancies estimated for England & Wales

0

5

10

15

20

25

30

35

40

70-72

73-75

76-78

79-81

82-84

85-87

88-90

91-93

94-96

deaths direct assoc.freq.per million% direct deaths

Pattern of maternal deaths US.assoc.with anesthesiaPattern of maternal deaths US.assoc.with anesthesia

NY 1979-81;Indiana 60-80NY 1979-81;Indiana 60-80

IndianaIndiana

Aspir ofgastric content

Aspir ofgastric content

cardioresoarrest

cardioresoarrest

N.YN.Y

12 GA12 GA

Aspir of gastriccontent

Aspir of gastriccontent

cardioresoarst

cardioresoarst

cardiacarrest

cardiacarrest

1 RA(bupii.v.)

1 RA(bupii.v.)

Patterns of maternal mortality associated withanesthesia

Patterns of maternal mortality associated withanesthesia

Enngland & WalesEnngland & Wales

1970-781970-78

68 from GA:40 aspiration,28 oti problems68 from GA:40 aspiration,28 oti problems

1985-871985-87

7 from GA:5 error in OTI;1 aspiration,1 kinkedETT7 from GA:5 error in OTI;1 aspiration,1 kinkedETT

1 from reg;cardiovasc collpase under epiduralblock in a patient with aortic insuff.1 from reg;cardiovasc collpase under epiduralblock in a patient with aortic insuff.

Incidence of failed iot

• Hawthorne, L.; Wilson, R.; Lyons, G.; Dresner, M. Failed intubation revisited: 17-yr experience in a teaching maternity unit

• Br. J. Anaesth. 1996; 76:680-684.

• 16 years at St James

• 5802 GA * C/S

• 0.4% failed IOT;1/300 1984,1/250 1994.

Failed IOT frequency(Tsen et al,Int J.Obset Anesth. 1998;7:147)

0

2

4

6

8

10

12

14

16

1990 1991 1992 1993 1994 1995

iot fallite

Mallampati Score changes during pregnancy

(Piklington et al,BJA 1995;74:638)

0

10

20

30

40

50

60

%

1 2 3 4

12-set38 sett

score

Difficult OTI increase in obstetrics

0

0,2

0,4

0,6

0,8

1

1,2

1,4

1,6

1,8

%

score 3

chir genC/S (Pilk)C/S (Durban)ost (Carli)

Difficult OTI etiology

• Anatomical variations

• Organizational factors:– inexperience– Extra hours emerg.– “stat” mentality– panic

0

10

20

30

40

50

60

70

80

90

%

elettive emergenza

Iot fallite e tipo di C/S(Hawthorn,BJA 1996

% AG

fallite

Unnecessary GA

• Inadequate patient education• Surgeons habits• Late call• Surpassed indications:

– preeclampsia– placenta praevia– fever– Cardiac disease

Difficult intubation cart:

• In OR:• Choice of laryngoscopes:handles and blades

• Guedel,Copa

• LMA ,:Proseal…

• Combitube

• ventlating bougies,hockey club…

• Crico- thiroidotomy set:Patil,Ravussin,ecc

• FBS.

• jet ventilation……...

Risk factors evaluation • Anretenatal visit

• 90% of urgent C/S can be prevented (risk factors…)

• Pre..emptive pd. To avoid GA.(Morgan et al.Anesthesia for emergency cesarean

section.Br.J Obstet.Gynecol. 1990;97:420-24).• Large study pf outpatient obstetric anesthesia clinic:(Hamza et

al.Anesthesia consultaion can decrease the need for general anesthesia for emergency cesarean section in parturients with difficult airway.Br.J.Anesth

1995;74:A353.):10%present at least 1 Risk factor for difficult OTI

Hawkins JL,Koonin LM,Palmer SK,Gibbs CP.Anesthesia related deaths during obstetric delivery in the United States(Anesthesiology

1997;86:277-84).• Maternal deaths reported in USA 1979-

1990

• cause

• relation to anesthetic

• type of obstetric procedure

• associated maternal conditions.

Estimates from CDC USAEstimates from CDC USA

1979-841979-84Cs 19%Cs 19%

GA 41%,REG 55%GA 41%,REG 55%

1990-921990-92CS 24%CS 24%

GA 16%,REG 84%GA 16%,REG 84%

MortalityMortality82% from CS82% from CS

Hawkins JL,Koonin LM,Palmer SK,Gibbs CP.Anesthesia related deaths during obstetric delivery in the United States(Anesthesiology

1997;86:277-84).

02468

1012141618

%

79-81 82-84 85-87 88-90

num.tot=129

GAREGunknownsedation

Maternal mortality and anesthesia

• 4.3/milion live births ( 1979—1981)

• 1.7/ milion live births (1988—1990).

• 8.7/ milion live births( 1979—1981)

• 1.7/ milion live births (1988—1990).

CDC USA CEMDEW

From CDC USA fatalities :GA vs reg.

• GA 2.3 > reg (1979—1984)

• GA 16.7 > reg ( 1985—1990).

Complication rate AG * C/S: CDC USA

• Deaths:

• 20.0/million GA ( 1979—1984)

• 32.3 /million (1985—1990)

Mortality ( CS )in Reg anest CDC USA

• 8.6 /million of Reg anest.( 1979—1984)

• 1.9 /million ( 1985—1990).

Chadwick,HS,Posner,K,Kaplan,RA,Ward,RJ,Cheney FW.A comparison of obstetric and

nonobstetric anesthesia malpractice claims.Anesthesiology 1991;74:242-249.

• ASA closed claims project

• Malpractice claims against anesthesiologists

• ob vs non ob:190 vs 1351– ob cases :67% CS,33% vaginal– 65% assoc with Reg anest,;33% with GA– 2 claims * anesth not available!

Damaging events in obs vs nonobs claims

0

2

4

6

8

10

12

14

%

ob nonob

inadeq.ventilationdifficult intubpulm.aspir.esoph.intubbronchospasminadeq.FiO2airways obstruct.estubaz prematuraconvulsequipment problemsdrug mistakefluid mistakeblood losstrans.mistake

*

*

*

Probl.resp

Probl cardiocirc

Maternal damage:CS vs vaginal delivery

0

5

10

15

20

25

%

CS vag

maternal deathneonatal cerebral damageheadacheneonatal deathpain during anesth.neural damagecerebral damage pt)emotional distress dorsalgia

*

Obstetrical claims;reg vs ga

0

5

10

15

20

25

30

35

40

45

%

reg GA

maternal deathneonatal cerebral damageheadacheneonatal deathpain during anesth.neural damagecerebral damage pt)emotional distress dorsalgia

*

*

**

Neonatal damageNeonatal damagepathogenesispathogenesis

45% :anesthesia related45% :anesthesia related

4 GA :1 bronchospasm,1 oesophag.intub,1 pulm.aspir,1anesth,delay; polm,1 anesth delay) ,13 reg:,9 convulsafter intravasc adm;1 eclampsia,1 medicaldelay,3 high spinal

4 GA :1 bronchospasm,1 oesophag.intub,1 pulm.aspir,1anesth,delay; polm,1 anesth delay) ,13 reg:,9 convulsafter intravasc adm;1 eclampsia,1 medicaldelay,3 high spinal

37% : obstetrical or congenital problems37% : obstetrical or congenital problems

13% resuscitation problems13% resuscitation problems

Pulmonary inhalationPulmonary inhalation

8% ob claims vs 2% non ob claims8% ob claims vs 2% non ob claims

50% associated with difficult intub;oesophageal orinadequate ventilation

50% associated with difficult intub;oesophageal orinadequate ventilation

14/16 associated with GA14/16 associated with GA

7 cases of mask anesth & 6 cases of oesophageal intub.or difficult intubation7 cases of mask anesth & 6 cases of oesophageal intub.or difficult intubation

2 cases associated with reg anesth2 cases associated with reg anesth

Tetrac 20 mg and 4 administered by the obs-resp insuff-ETT after 6-7 min byanesth--hypoxiaTetrac 20 mg and 4 administered by the obs-resp insuff-ETT after 6-7 min byanesth--hypoxia

ConvulsionsConvulsions

10% in ob claims vs 1% non ob claims10% in ob claims vs 1% non ob claims

83% associated with severe neurological damage ,maternaland/or neonatal death

83% associated with severe neurological damage ,maternaland/or neonatal death

18/19 during epid.anest.18/19 during epid.anest.

10/17 no test dose w.adr10/17 no test dose w.adr

15/17 bupi…15/17 bupi…

2/19 eclampsia2/19 eclampsia

Equipment problemsEquipment problems

5/11 :epid cath.teared5/11 :epid cath.teared

non functioning defibnon functioning defib

5 ventilator problems5 ventilator problems

exp side connected to the ventilatorexp side connected to the ventilator

circuitry errorcircuitry error

N2 in circuitN2 in circuit

Damage severity classification

• Temporary: 0:not obvious 1: emotional fear,pain… 2:not signif:;lacer,contus,no

recovery retardation 3:minor.eg.g.fall,recovery

retard. 4:major;cerebral

damage,neurologic,recovery retard.

• Permanent 5:minor:organ damage,not

debil.; 6:significant;e.g.eye or

kidney loss, 7:major;paraplegia,blindness,cerebral damage

8:severe:;severe cerebral damage,quadriplegia, life care

9:death.

Severity Injury Score (SIS)

• Ob: SIS median 3 vs non ob ,median 7

• Max SIS equal

• But different distribution……….

• Median + after GA; maternal death 47% of claims in AG vs 12% after reg.

05

1015

2025

3035

40

%

minore(0-3) magg(4-6) invalidità(7-8)

morte(9)

ob

non ob

Payment data in $

reg gen

not paid(%) 32 38 43 27

paid (%) 59 53 48 63

median payment 85000 203000 91000 225000

payment ange range 15000-6 mil 675000-5.4 mil 675-2.5 mil 750-5.4 mil

GA paid 63% vs 48% reg.

Conclusions from the closed claims:1Conclusions from the closed claims:1

cerebral neonatal damagecerebral neonatal damage

50% not anesth.related50% not anesth.related

median payment:500.000$vs 120.000 for other

ob.claims

median payment:500.000$vs 120.000 for other

ob.claims

Conclusions from the closedclaims

Conclusions from the closedclaims

HeadacheHeadache

3rd complaint3rd complaint

payment in 56%payment in 56%

Maternal sequelae post partum:from Crawford 1978-85.

• Birmingham,UK,11701 questionn. in 30096 deliveries:

• dorsalgia 14%• headache 4%• Parestesth.:hands 2.5%,lower limbs 0,2 %

(Reg anest)• Bladder stress incontinence 15%,disuria 4%

(prolonged labors,forceps..)

Scott DB, Hibbard BM. Serious non-fatal complicationsassociated with extradural block in obstetric practice.

Scott DB, Hibbard BM. Serious non-fatal complicationsassociated with extradural block in obstetric practice.

British Journal of Anaesthesia 1990; 64:537-541.British Journal of Anaesthesia 1990; 64:537-541.

505.000 extradural blocks:i,84% labour;16% C/S ( 203 units,,1982-86, 2.580.000

deliveries:

505.000 extradural blocks:i,84% labour;16% C/S ( 203 units,,1982-86, 2.580.000

deliveries:

108 events;5 permanent sequelae108 events;5 permanent sequelae

60 acute reactions60 acute reactions

Scott DB, Hibbard BM. Serious non-fatal complicationsassociated with extradural block in obstetric practice.

Scott DB, Hibbard BM. Serious non-fatal complicationsassociated with extradural block in obstetric practice.

5 cranial nn palsies5 cranial nn palsies

1 subd hematoma(accid.dural punct)1 subd hematoma(accid.dural punct)

38 periph.neuropathies(single nerve)38 periph.neuropathies(single nerve)

1 quadriplegia (thrombosis of cervical haemangioma)1 quadriplegia (thrombosis of cervical haemangioma)

1 paraplegia1 paraplegia

1 abscess & 1 subdural hematoma (evacuated withsuccess)

1 abscess & 1 subdural hematoma (evacuated withsuccess)

Scott DB, Tunstall ME. Serious complicationsassociated with epidural/spinal blockade in obstetrics.

Scott DB, Tunstall ME. Serious complicationsassociated with epidural/spinal blockade in obstetrics.

International Journal of Obstetric Anesthesia 1995; 4:131-137. eadingsInternational Journal of Obstetric Anesthesia 1995; 4:131-137. eadings

obs anesthesiologists surveyobs anesthesiologists survey

123000 blocks/216816 deliveries123000 blocks/216816 deliveries

46 isolated neuropathies of a single spinal nerve46 isolated neuropathies of a single spinal nerve

8 cases of prolonged urinary retention8 cases of prolonged urinary retention

Holdcroft A, Gibberd FB, Hargrove RL, Hawkins DF, Dellaportas CI. Neurological complicationsassociated with pregnancy. British Journal of Anaesthesia 1995; 75:522-526.

Holdcroft A, Gibberd FB, Hargrove RL, Hawkins DF, Dellaportas CI. Neurological complicationsassociated with pregnancy. British Journal of Anaesthesia 1995; 75:522-526.

all 48066 deliv of North West Thames in 1 year:19 neurological disturbancesall 48066 deliv of North West Thames in 1 year:19 neurological disturbances

2 hypoxic cerebr.damage2 hypoxic cerebr.damage

1 post cardiac arrest(myopathia):exitus1 post cardiac arrest(myopathia):exitus

1 following haemorrhage :residual tetraparesis1 following haemorrhage :residual tetraparesis

5 neural root damage5 neural root damage

Bell,cervical,L5 disc prolapse,preexisting sciatica,foot drop(spontaneousdelivery under nitrous oxide analgesia of a large baby via a small pelvis)Bell,cervical,L5 disc prolapse,preexisting sciatica,foot drop(spontaneousdelivery under nitrous oxide analgesia of a large baby via a small pelvis)

Holdcroft et al. Neurological complications associated withpregnancy. British Journal of Anaesthesia 1995; 75:522-526.Holdcroft et al. Neurological complications associated with

pregnancy. British Journal of Anaesthesia 1995; 75:522-526.

3 periph.nn.paralysis:lat.pop.,ulnar,meralgia parestetica3 periph.nn.paralysis:lat.pop.,ulnar,meralgia parestetica

5 medical concauses5 medical concauses

2 from space occup.lesions,1 mult.scler.,1 diabetic ,1meningitis

2 from space occup.lesions,1 mult.scler.,1 diabetic ,1meningitis

2 dorsal pain2 dorsal pain

1 paresth.of a neural root dstrib.1 paresth.of a neural root dstrib.

Neurological complications associated with Reganesth

Neurological complications associated with Reganesth

78 cases in Medline within 1998:Lee CC.Int J Obstet.Anest78 cases in Medline within 1998:Lee CC.Int J Obstet.Anest

epid.abscessepid.abscess

meningitismeningitis

aseptic meningitisaseptic meningitis

aracnoiditisaracnoiditis

spinal hematomaspinal hematoma

subdural cranial hematomasubdural cranial hematoma

ant spinalis art.syndromeant spinalis art.syndrome

cranial nn.palsiescranial nn.palsies

direct trauma(catheter,needle...)direct trauma(catheter,needle...)

Why do we have problems withobstetric analgesia

Why do we have problems withobstetric analgesia

joy/damagejoy/damage

anesthesiologistvisibility

anesthesiologistvisibility

obstetricians"scaricabarile"obstetricians

"scaricabarile"

invisibilitythe fetal

head

invisibilitythe fetal

head

preference forregional

anesthesia

preference forregional

anesthesia

Eziologia del danno neurologico in ostetricia

• Cause mediche intercorrenti;– ascesso o ematoma epidurale spontaneo– esacerbazione di:

• malattie del collagene• patologie vascolari• polineuropatie• neuriti postinfettive• sclerosi multipla

• discesa del feto nella pelvi:– compressione del tronco lombosacrale;

• nn.sciatico,femorale,otturatorio,lat.cutaneo,peroneo comune……..

• anestesia regionale per se

Etiology of neurological sequelaeEtiology of neurological sequelaeunrelated to regional anesthesiaunrelated to regional anesthesia

surgical position,delivery positionsurgical position,delivery position

surgical trauma(forceps)surgical trauma(forceps)

(cast and dressing application)(cast and dressing application)

compression by tourniquet,stirrups,fetal head ....compression by tourniquet,stirrups,fetal head ....

undiagnosed neurological disease:spont epid.abscess or hematomaundiagnosed neurological disease:spont epid.abscess or hematoma

exacerbation of collagen dis.,vascular,polyneuropathy,multsclerosis,postinfectious neuritis....

exacerbation of collagen dis.,vascular,polyneuropathy,multsclerosis,postinfectious neuritis....

Etiology of neurological complicationsEtiology of neurological complicationsrelated to reg.anesthrelated to reg.anesth

neurotoxicityneurotoxicity

direct neural tissue injurydirect neural tissue injury

spinal hematomaspinal hematoma

spinal abscessspinal abscess

meningitismeningitis

ischemiaischemia

reg.anesth.per sereg.anesth.per sedirect trauma by needle,catheter,injection...direct trauma by needle,catheter,injection...

Incidence of motor defict following epidural anesthesia

• Author cases incid /10.000• Dawkins 32718 14.7/2.1(trans/perm)• Crawford 2035 0• Aboulesih 1417 14.1• Bonica 3637 2.7• Lund 10000 1• Hellman 26127 0• Moore 6729 0• Bleyaert 3000 0 • Ong 9403 0.8

Neurological complications of regional anesthesia in obstetrics

• Kandel (1965);0 / 1000• Crawford(1972);0 / 1035• Holdcroft(1976);1 7 1000• Bleyaert(1979);0 / 3000• Abouleish(1981);3 / 1417• Crawfoed(1985);4 / 27000• Ong(1987);34 / 9403• Scott(1990);43 / 505000• Scott(1995):38 / 108133• Holdcroft(1995);1 / 13007• Puech(1999);1 / 10995

Maternal injury files(Chadwick)• 356 cases: n. %• maternal death: 83 23• headache 64 18• nerve/spinal cord trauma 41 12• pain anesth 37 10• back pain 34 10• brain damage 32 9• emotional distress 31 9• aspiration pneumonitis 20 6

NeurotoxicityNeurotoxicity

ChloroprocaineChloroprocaine

5% lidocaine5% lidocaine

TRI....TRI....

TRITRIuneventful single shot spinal anesthesiauneventful single shot spinal anesthesia

low back painlow back pain

dysesthesiasdysesthesias

radiation to the thighradiation to the thigh

hyperbaric 5% lidocainehyperbaric 5% lidocaine

cauda equina syndromecauda equina syndrometox.of LA spinal anesthetics?tox.of LA spinal anesthetics?

paraparesis,paraplegia,numbnessin the saddle area,incompretence

of bladder and anal sphincter

paraparesis,paraplegia,numbnessin the saddle area,incompretence

of bladder and anal sphincter

permanent deficitspermanent deficits

High subarachnoid blockHigh subarachnoid block

high spinal dosehigh spinal dose

continuous spinalcontinuous spinal

inadvertent spinal from epidural.inadvertent spinal from epidural.

repeated injections after failed spinal..repeated injections after failed spinal..

Top ups :attention!Top ups :attention!

Incidence of paresthesias following epidural anesthesia

• Author cases incid /10.000

• Crawford 2035 14.7

• Eisen 9532 16.8

• Abouleish 1417 42.3

• Lund 10000 5

• Bonica 3637 24.7

• ONG 9403 36.2

Ong BY,Cohen MM,Esmail A,Cumming M,Kozody R,Palahniuk RJ.Paresthesias and motor dysfunction after labor and

delivery.AA,1987;66:18-22.• Winnipeg Women Hospital,1975-83,23827 deliveries• analg/anesth applied:

– none 8198

– inhalatory analg. 4766

– epid.analg 9403

– GA 864

– other 381

– not codif 215

– delivery:• spont. vag. 53.4%

• forceps//vacuum 27.9%

• C/S 18.6%

Paresthesias and motor dysfunction after labor and delivery

Incidence of paresthesias& motor dysfunction:18.9/10.000(45 cases)

05

10152025303540

/10.

000

multiparprimiparvag spontforceps,vacuumno analganalg. Inalatepid onlyGA

* ** *

Other problems associated with anesth/analg:

• PDPH• Assoc with cranial subdural hematoma:8

cases <1990 Medline

• assoc with cranial nn.palsies;diplopia,tinitus,vertigo……..

• Long term dorsalgia………...

Accidental dural puncture

rates(Cowan IJOA 2001;10:1-16)• Incidence:0.25-0.5%

• reduced dural puncture;frequence

• experience

• non rotation of the needle

• choice of technique:lateral decubitus+loss of resist with saline+non rotation of needle

Dural puncture ko

• Pdph.80% FOLLOWING LARGE NEEDLES

• cranial nerve palsy;1-3.7%:abducens vestibulocochlear…:gen benign,rare,may take months to resolve

• cranial subdural haematoma;1/500.000(Scott 1990)

• Any persistent postspinal headache or recurrence of it should alert the anesthesiologist………

» LOO IJOA 2000

PDPH DD

• Headaches:• Migraine• fatigue,• anxiety,• post partun blues,• pp depression• preexistent headache,• Musc. contraction • depress.equiv and conversion reaction• Cluster• Analgersics abuse(Olesen BMJ 1995)

Long term morbidity following dural puncture(Jeskin IJOA

2001;10:17-24.)

• Case controled retrospective mail survey

• 194 mother with accidental dural pun.

• Low response rate

• 18% long term headache(3.6 years)

• following spinal anesth 0.89% > 1 year

Petroclinoid ligament

Peripartum paralysis

• Trauma :.peripheral/central

• vascular:epidural hematoma,spinal cord ischemia,anterior spinal artery syndrome– chemical;neurotoxicity– infection:epidural abscess,meningitis,tbc,HIV– congenital;syringomielia,spinal cyst,AVM– new growths;tumor– degeneration:herniated disc,spinal stenosis,Paget..

Etiology of paralysisEtiology of paralysis

coexistingdisease

coexistingdisease

iatrogeniciatrogenic

intraspinalsepsis

intraspinalsepsis

parturitionprocess

parturitionprocess

visibility of reg anesth....visibility of reg anesth....

Visibility of reg anesth…..

Nerve traumaNerve traumaAuroy,Y.Anesthesiology 97;87:479-86 &Auroy,Y.Anesthesiology 97;87:479-86 &

Scott IJOA 95;4:133-9.Scott IJOA 95;4:133-9.

NumberNumber

24/40640 & 38/505.00024/40640 & 38/505.000

clinical presentationclinical presentation

paresthesia during puncture or pain during injectionparesthesia during puncture or pain during injection

resulting radiculopathyresulting radiculopathy

same topgraphy as the associated paresth.same topgraphy as the associated paresth.

prognosisprognosis

reversible <15gg (3 mon);2 cases persistentreversible <15gg (3 mon);2 cases persistent

Foetal head descent

Maternal obstetric palsiesMaternal obstetric palsiesBademosi,Int J Obstet.Gynecol 1980;17:611-614Bademosi,Int J Obstet.Gynecol 1980;17:611-614

Plexus injury 85%(29 cases)Plexus injury 85%(29 cases)

Spinal cord injury 15%(5 cases)Spinal cord injury 15%(5 cases)

Paresthesia and nerve damage following CSE & spinal(Holloway et al IjOA 2000;9:151-55)

0

10

20

30

40

50

60

non surg surgical uncertain all

CSESSSall

Damage to the conus medullarisfollowing spinal anesthesia

Damage to the conus medullarisfollowing spinal anesthesia

Reynolds,F.Anaesthesia 2001;56:238-47Reynolds,F.Anaesthesia 2001;56:238-47

6 cases6 cases

pain on insertion alwayspain on insertion always

Syrinx at MRI:always coincident with neurologySyrinx at MRI:always coincident with neurology

urinary problems:50%urinary problems:50%

sensory problems unilat;L4 /L5-s1-s3sensory problems unilat;L4 /L5-s1-s3

motor impairment:foot dropmotor impairment:foot drop

Position of the tip of the conus medullaris as referred tothe adjacent third of the vertebral body or disc space.

Position of the tip of the conus medullaris as referred tothe adjacent third of the vertebral body or disc space.

frequency distribution for conus levelfrequency distribution for conus level

countcount%%

T12M3T12M3 99 1,791,79

T12L3T12L3 2020 3,973,97

T12/L1T12/L1 3333 6,556,55

L1U3L1U3 575711,3111,31

L1M3L1M3 686813,6913,69

L1I3L1I3 127127 25,225,2

L1/L2L1/L2 828216,2716,27

L2U3L2U3 6060 11,911,9

L2M3L2M3 2727 5,365,36

L2I3L2I3 1414 2,782,78

L2/L3L2/L3 55 0,990,99

L3U3L3U3 11 0,20,2

The level of PL was falsely evaluated in 62% of cases.puncture performed 1-2 interspaces higher than

assumed…(Van Gassel 1993)

Broadbent et al Anesthesia 2000

T12-L1

L1-L2

L2-L3

L3-L4

L4-L5

L5-S1

S1-S2

T11-T12

2 3 1

T12-L1

10 4 2

L1-L2

1 16 39 24

L2-L3

5 26 45

L3-L4

13 5

L4-L5

2

L5-S1 1 1

Actual level

Anesthesiologist opinion

Inability to identify correctly theintervertebral spaces

Inability to identify correctly theintervertebral spaces

"provare per credere""provare per credere"

Correct identificationCorrect identification only 29% of casesonly 29% of cases

actual interspaceactual interspace1-4 interspaces higherthan assumed in 68% ofcases

1-4 interspaces higherthan assumed in 68% ofcases

it cannot be recommended to insert thespinal needle higher than L3-L4 at the

highest.

it cannot be recommended to insert thespinal needle higher than L3-L4 at the

highest.

Reynolds Anesthesia2000Reynolds Anesthesia2000

In pregnant patients at term cephalic pelvic tilt may further displace the apparent intercristal

line in a cephalad direction...:

Risk of epidural abscessRisk of epidural abscess

laborlabor

1/500.000(Scott)--1/27.000 Crawford1/500.000(Scott)--1/27.000 Crawford

epid anesth.epid anesth.

1/75.000(Acta Anesth.Scand 1987-95)1/75.000(Acta Anesth.Scand 1987-95)

45 cases in Medline(Schneidr,com WCA2000)45 cases in Medline(Schneidr,com WCA2000)

Epidural abscessEpidural abscess

SpontaneousSpontaneous

5 cases;5 cases;

haematogenous spread from vaginahaematogenous spread from vagina

Staph aureus/Gr B streptococcusStaph aureus/Gr B streptococcus

associated with peridural anesth.associated with peridural anesth.

incidence:0.2-3.7/100.000incidence:0.2-3.7/100.000

staph aureus(bact typing)staph aureus(bact typing)

risk incr with the catetherization length.risk incr with the catetherization length.

Loo 2000 JIOA;9:99-104.Loo 2000 JIOA;9:99-104.

Epidural abscessEpidural abscessClinical featuresClinical features

spinalachespinalache

nerve root painnerve root pain

weaknessweakness

paralysisparalysis

feverfever

WBC+WBC+

reflexes alterationreflexes alteration

neck stiffnessneck stiffness

headacheheadache

aggressive surgical treatmentaggressive surgical treatment

A ggressive surgical management(drainage???A ggressive surgical management(drainage???

Blood cult(25%+)

MRI gadol enh.

MeningitisMeningitisbacterialbacterial

associated with RAassociated with RA

Streptococcus 40%,pseud aer 20%,sraph epidermid 7%Streptococcus 40%,pseud aer 20%,sraph epidermid 7%

spontaneousspontaneous

Strept pneum,N.mening.,Haem infl.Strept pneum,N.mening.,Haem infl.

SPI>>epidSPI>>epid

Loo 2000 IJOA,;9:99-104. & Scheenberger Infection 96;24:29-35.Loo 2000 IJOA,;9:99-104. & Scheenberger Infection 96;24:29-35.

>'83 shift from Gram neg to alpha haem.streptococ.>'83 shift from Gram neg to alpha haem.streptococ.

MeningitisMeningitisincidence 3/65000 spi(Kane,1982);incidence 3/65000 spi(Kane,1982);

1/100.000 epid(Palot 1994)1/100.000 epid(Palot 1994)

risk factors:risk factors:

dural puncture?dural puncture?

not wearing a face mask?not wearing a face mask?

????

Prevention of epi/spinal infectionsPrevention of epi/spinal infectionsalwaysalways

surg.prepsurg.prep

filtersfilters

do not leave catheters if not necessary----do not leave catheters if not necessary----

asepsis for every injectionasepsis for every injection

Spinal epidural haematomaSpinal epidural haematomareluctance to report......reluctance to report......

Scott-HibbardScott-Hibbard

0,0020,002

Hodlcroft,Paech,Scott,Tunstall(prospective)Hodlcroft,Paech,Scott,Tunstall(prospective)

182.000 blocks & no problem...182.000 blocks & no problem...

Vandermeulen:11 surveysVandermeulen:11 surveys

258987 spi, 65304 epi..no problem258987 spi, 65304 epi..no problem

Spinal haematoma in absence ofcoagulopathy or thromboprophylaxis

Spinal haematoma in absence ofcoagulopathy or thromboprophylaxis

extremely rareextremely rare

risk factorsrisk factors

difficult multiple punctures.difficult multiple punctures.

bloody puncturesbloody punctures

epid catheter insertionepid catheter insertion

removal of an epid.catetherremoval of an epid.catether

Risk of spinal / epidural haematomaRisk of spinal / epidural haematomadata form large surveys..data form large surveys..

labour:labour:

epidural:1/500.000(scott 1990)epidural:1/500.000(scott 1990)

spinal:0spinal:0

operativeoperative

peridural;1:190.000(CI 1/4060000-1/97000)(Wolf-Tryba)peridural;1:190.000(CI 1/4060000-1/97000)(Wolf-Tryba)

spinal :1/240000spinal :1/240000

Guidelins for safe epidural (spinal)practice

Guidelins for safe epidural (spinal)practice

from H Breivik & Co.from H Breivik & Co.

strict aseptic techniquestrict aseptic technique

in case of prolonged epid.pain control maintain analgesia with minimal motor blockin case of prolonged epid.pain control maintain analgesia with minimal motor block

daily monitoring of the catheter insertion sitedaily monitoring of the catheter insertion site

continuous surveillance for any increasing leg weaknesscontinuous surveillance for any increasing leg weakness

teaching programme for nurses and medical staffteaching programme for nurses and medical staff

inform the patient of the significance of leg weaknessinform the patient of the significance of leg weakness

high index of diagnostic suspicionhigh index of diagnostic suspicion

high preparedness for rapid handlinghigh preparedness for rapid handling

Conclusions from neurological complications attributed to

labor and delivery• Not rare(estim.incid 1: 2530

• often accompanied by a prolonged and difficult labor

• if assoc with regional anesth,again associated with a prolonged and difficult labor

• :they do not constitute a risk factor per se

• but…call for higher standards of practice

Control & prevention

• Standards of care

• total quality management:– evaluation of individual risk/benefit– patient control – complications audit– training of the team rsponsible of peripartum

are– information on possible complications