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Hideo Yasunaga - One of the best experts on this subject based on the ideXlab platform.
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spinal epidural hematoma and abscess after Neuraxial Anesthesia a historical cohort study using the japanese diagnosis procedure combination database
Canadian Journal of Anaesthesia-journal Canadien D Anesthesie, 2020Co-Authors: Kanako Makito, Hideyuki Mouri, Hiroki Matsui, Nobuaki Michihata, Kiyohide Fushimi, Hideo YasunagaAbstract:BACKGROUND Spinal epidural hematoma and abscess are rare complications of Neuraxial Anesthesia but can cause severe neurologic deficits. The incidence of these complications vary widely in existing studies and the risk factors remain uncertain. We estimated the incidence of these complications and explored associations using a national inpatient database in Japan. METHODS Using Japanese Diagnosis Procedure Combination data on surgical inpatients who underwent Neuraxial Anesthesia from July 2010 to March 2017, we identified patients with spinal epidural hematoma and/or abscess. We investigated age, sex, Charlson comorbidity index, antithrombotic therapy, type of surgery, admission, and hospital for association with these complications. The incidences of spinal epidural hematoma and abscess were estimated separately, and a nested case-control study was performed to examine factors associated with these complications. RESULTS We identified 139 patients with spinal epidural hematoma and/or abscess among 3,833,620 surgical patients undergoing Neuraxial Anesthesia. The incidences of spinal epidural hematoma and abscess were 27 (95% confidence interval [CI], 22 to 32) and 10 (7 to 13) per one million patients, respectively. Spinal Anesthesia was associated with significantly fewer complications compared with epidural or combined spinal epidural Anesthesia (odds ratio, 0.15; 95% CI, 0.08 to 0.32). Antiplatelet agent (odds ratio, 0.49; 95% CI, 0.06 to 3.91) and anticoagulants (odds ratio, 1.65; 95% CI, 0.95 to 2.85) were not significantly associated with these complications. CONCLUSIONS This analysis identified the incidences of spinal epidural hematoma and/or abscess after Neuraxial Anesthesia. Additional large-scale studies are warranted to examine the incidences and factors associated with these complications.
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Spinal epidural hematoma and abscess after Neuraxial Anesthesia: a historical cohort study using the Japanese Diagnosis Procedure Combination database
Canadian Journal of Anesthesia Journal canadien d'anesthésie, 2020Co-Authors: Kanako Makito, Hideyuki Mouri, Hiroki Matsui, Nobuaki Michihata, Kiyohide Fushimi, Hideo YasunagaAbstract:Contexte Les hématomes et abcès périduraux sont des complications rares de l’anesthésie Neuraxiale qui peuvent toutefois provoquer des atteintes neurologiques graves. L’incidence de ces complications est très variable dans les études existantes et les facteurs de risque demeurent incertains. Nous avons estimé l’incidence de ces complications et exploré les associations en analysant une base de données nationale des patients hospitalisés au Japon. Méthode En nous fondant sur la base de données japonaise Diagnosis Procedure Combination (DPC – un système de paiement des soins de santé uniformisé) de juillet 2010 et mars 2017, nous avons identifié les patients chirurgicaux hospitalisés ayant reçu une anesthésie Neuraxiale et ayant souffert d’un hématome et/ou d’un abcès péridural. Nous avons examiné l’âge, le sexe, l’indice de comorbidité de Charlson, le traitement antithrombotique, le type de chirurgie, l’admission et l’établissement pour déterminer si ces facteurs étaient associés à ces complications. Les incidences d’hématomes et d’abcès périduraux rachidiens ont été séparément estimées, et une étude cas témoins imbriquée a été réalisée pour examiner les facteurs associés à ces complications. Résultats Nous avons identifié 139 patients ayant souffert d’un hématome et/ou d’un abcès péridural parmi les 3 833 620 patients chirurgicaux ayant reçu une anesthésie Neuraxiale. Les incidences d’hématome et d’abcès périduraux rachidiens étaient de 27 (intervalle de confiance [IC] 95 %, 22 à 32) et 10 (7 à 13) par million de patients, respectivement. La rachianesthésie était associée à un nombre significativement plus faible de complications comparativement à une anesthésie péridurale ou péridurale rachidienne combinée (rapport de cotes, 0,15; IC 95 %, 0,08 à 0,32). Aucune association significative n’a été observée entre les agents antiplaquettaires (rapport de cotes, 0,49; IC 95 %, 0,06 à 3,91) ou les anticoagulants (rapport de cotes, 1,65; IC 95 %, 0,95 à 2,85) et ces complications. Conclusion Cette analyse a identifié les incidences d’hématome et/ou d’abcès péridural après une anesthésie Neuraxiale. Des études supplémentaires de grande envergure sont nécessaires pour examiner les incidences et les facteurs associés à ces complications. Background Spinal epidural hematoma and abscess are rare complications of Neuraxial Anesthesia but can cause severe neurologic deficits. The incidence of these complications vary widely in existing studies and the risk factors remain uncertain. We estimated the incidence of these complications and explored associations using a national inpatient database in Japan. Methods Using Japanese Diagnosis Procedure Combination data on surgical inpatients who underwent Neuraxial Anesthesia from July 2010 to March 2017, we identified patients with spinal epidural hematoma and/or abscess. We investigated age, sex, Charlson comorbidity index, antithrombotic therapy, type of surgery, admission, and hospital for association with these complications. The incidences of spinal epidural hematoma and abscess were estimated separately, and a nested case-control study was performed to examine factors associated with these complications. Results We identified 139 patients with spinal epidural hematoma and/or abscess among 3,833,620 surgical patients undergoing Neuraxial Anesthesia. The incidences of spinal epidural hematoma and abscess were 27 (95% confidence interval [CI], 22 to 32) and 10 (7 to 13) per one million patients, respectively. Spinal Anesthesia was associated with significantly fewer complications compared with epidural or combined spinal epidural Anesthesia (odds ratio, 0.15; 95% CI, 0.08 to 0.32). Antiplatelet agent (odds ratio, 0.49; 95% CI, 0.06 to 3.91) and anticoagulants (odds ratio, 1.65; 95% CI, 0.95 to 2.85) were not significantly associated with these complications. Conclusions This analysis identified the incidences of spinal epidural hematoma and/or abscess after Neuraxial Anesthesia. Additional large-scale studies are warranted to examine the incidences and factors associated with these complications.
Lisa Leffert - One of the best experts on this subject based on the ideXlab platform.
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Pragmatic approach to Neuraxial Anesthesia in obstetric patients with disorders of the vertebral column, spinal cord and neuromuscular system.
Regional Anesthesia & Pain Medicine, 2020Co-Authors: Elisa Walsh, Yi Zhang, Hannah Madden, James Lehrich, Lisa LeffertAbstract:Neuraxial Anesthesia provides optimal labor analgesia and cesarean delivery Anesthesia. Obstetric patients with disorders of the vertebral column, spinal cord and neuromuscular system present unique challenges to the anesthesiologist. Potential concerns include mechanical interference, patient injury and the need for imaging. Unfortunately, the existing literature regarding Neuraxial Anesthesia in these patients is largely limited to case series and rare retrospective studies. The lack of practice guidance may lead to unwarranted fear of patient harm and subsequent avoidance of Neuraxial Anesthesia for cesarean delivery or Neuraxial analgesia for labor, with additional risks of exposure to general Anesthesia. In this narrative review, we use available evidence to recommend a framework when considering Neuraxial Anesthesia for an obstetrical patient with Neuraxial pathology.
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Neuraxial Anesthesia in obstetric patients receiving thromboprophylaxis with unfractionated or low molecular weight heparin a systematic review of spinal epidural hematoma
Anesthesia & Analgesia, 2017Co-Authors: Lisa Leffert, Brendan Carvalho, Alexander J. Butwick, Heloise Dubois, Timothy T Houle, Ruth LandauAbstract:Venous thromboembolism remains a major source of morbidity and mortality in obstetrics with an incidence of 29.8/100,000 vaginal delivery hospitalizations; cesarean delivery confers a 4-fold increased risk of thromboembolism when compared with vaginal delivery. Revised national guidelines now stipulate that the majority of women delivering via cesarean and women at risk for ante- or postpartum venous thromboembolism receive mechanical or pharmacological thromboprophylaxis. This practice change has important implications for obstetric anesthesiologists concerned about the risk of spinal epidural hematoma (SEH) among anticoagulated women receiving Neuraxial Anesthesia. We conducted a systematic review of published English language studies (1952-2016) and of the US Anesthesia Closed Claims Project Database (1990-2013) to identify cases of SEH associated with Neuraxial Anesthesia and thromboprophylaxis. We also report on SEH in obstetric patients receiving thromboprophylaxis and Neuraxial Anesthesia without adherence to the American Society of Regional Anesthesia (ASRA) recommendations. In our review, we initially identified 736 publications of which 10 met inclusion criteria; these were combined with the 5 cases of SEH identified in 546 obstetric Anesthesia Closed Claims reviews. None of these publications revealed SEH associated with Neuraxial Anesthesia and thromboprophylaxis with unfractionated heparin or low-molecular-weight heparin in obstetric patients. Based on data from 6 reports, 28 parturients had their Neuraxial blockade before the minimum ASRA recommended time interval between the last anticoagulant dose and the Neuraxial procedure. Based on data from 2 reports, 52 parturients received Neuraxial Anesthesia without their low-molecular-weight heparin dose being discontinued during the intrapartum period. Although the very low level of evidence and high heterogeneity in these reports make it difficult to draw quantitative conclusions from this systematic review, it is encouraging that this comprehensive search did not identify a single case of SEH in an obstetric patient receiving thromboprophylaxis and Neuraxial Anesthesia. Analysis of large-scale registries (eg, the Anesthesia Incident Reporting System of the Anesthesia Quality Institute) with more granular clinical and pharmacological data is needed to assess the impact of these practice changes on obstetric SEH incidence. In the interim, optimal care of obstetric patients depends on multidisciplinary planning of anticoagulation dosing to facilitate Neuraxial Anesthesia and thoughtful weighing of the relative risks and benefits of providing versus withholding Neuraxial in favor of general Anesthesia.
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Neuraxial Anesthesia in Parturients with Intracranial Pathology: A Comprehensive Review and Reassessment of Risk
Anesthesiology, 2013Co-Authors: Lisa Leffert, Lee H. SchwammAbstract:Parturients with intracranial lesions are often assumed to have increased intracranial pressure, even in the absence of clinical and radiographic signs. The risk of herniation after an inadvertent dural puncture is frequently cited as a contraindication to Neuraxial Anesthesia. This article reviews the relevant literature on the use of Neuraxial Anesthesia in parturients with known intracranial pathology, and proposes a framework and recommendations for assessing risk of neurologic deterioration, with epidural analgesia or Anesthesia, or planned or inadvertent dural puncture. The authors illustrate these concepts with numerous case examples and provide guidance for the practicing anesthesiologist in determining the safety of Neuraxial Anesthesia.
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Clinical implications of Neuraxial Anesthesia in the parturient with scoliosis.
Anesthesia & Analgesia, 2009Co-Authors: Lisa LeffertAbstract:Scoliosis can pose challenges to the initiation and function of Neuraxial anesthetics. We reviewed the available literature exploring Neuraxial techniques in parturients with uncorrected or corrected (i.e., surgically instrumented) scoliosis. The 22 articles reported 117 attempted Neuraxial procedures (uncorrected n = 24 and corrected n = 93). Of these procedures, 79% of uncorrected patients and 69% of corrected patients were successfully managed with Neuraxial Anesthesia. Procedures were typically more challenging in corrected patients; 90% of all reported difficulties in this subgroup involved epidural anesthetics. Complications were reported in 3 of 103 patients. We provide suggestions for optimizing efficacy of Neuraxial techniques in these patients.
Ruth Landau - One of the best experts on this subject based on the ideXlab platform.
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Adding to the Denominator: A Case Report of Neuraxial Anesthesia for Cesarean Delivery in the Setting of Hemolysis, Elevated Liver Enzyme, Low Platelet, Thrombocytopenia, and Pulmonary Hypertension.
A & A Practice, 2020Co-Authors: Marie-louise Meng, Kyra Bernstein, Patrick Hussey, Ukachi N. Emeruwa, Mirella Mourad, Jennifer Haythe, Ruth LandauAbstract:The acceptable platelet count for the safe provision of Neuraxial Anesthesia in obstetric patients is unknown. Comorbidities may sway a provider to perform Neuraxial Anesthesia, despite thrombocytopenia, as the putative risk of spinal-epidural hematoma may not outweigh the risks associated with general Anesthesia. The case of a 22-year-old nulliparous woman undergoing a cesarean delivery with a new diagnosis of pulmonary hypertension and right heart failure, compounded with thrombocytopenia and possible Hemolysis, Elevated Liver Enzyme, and Low Platelet (HELLP) syndrome, is presented. Risks and benefits of general versus Neuraxial Anesthesia in this specific setting are reviewed.
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Neuraxial Anesthesia in obstetric patients receiving thromboprophylaxis with unfractionated or low molecular weight heparin a systematic review of spinal epidural hematoma
Anesthesia & Analgesia, 2017Co-Authors: Lisa Leffert, Brendan Carvalho, Alexander J. Butwick, Heloise Dubois, Timothy T Houle, Ruth LandauAbstract:Venous thromboembolism remains a major source of morbidity and mortality in obstetrics with an incidence of 29.8/100,000 vaginal delivery hospitalizations; cesarean delivery confers a 4-fold increased risk of thromboembolism when compared with vaginal delivery. Revised national guidelines now stipulate that the majority of women delivering via cesarean and women at risk for ante- or postpartum venous thromboembolism receive mechanical or pharmacological thromboprophylaxis. This practice change has important implications for obstetric anesthesiologists concerned about the risk of spinal epidural hematoma (SEH) among anticoagulated women receiving Neuraxial Anesthesia. We conducted a systematic review of published English language studies (1952-2016) and of the US Anesthesia Closed Claims Project Database (1990-2013) to identify cases of SEH associated with Neuraxial Anesthesia and thromboprophylaxis. We also report on SEH in obstetric patients receiving thromboprophylaxis and Neuraxial Anesthesia without adherence to the American Society of Regional Anesthesia (ASRA) recommendations. In our review, we initially identified 736 publications of which 10 met inclusion criteria; these were combined with the 5 cases of SEH identified in 546 obstetric Anesthesia Closed Claims reviews. None of these publications revealed SEH associated with Neuraxial Anesthesia and thromboprophylaxis with unfractionated heparin or low-molecular-weight heparin in obstetric patients. Based on data from 6 reports, 28 parturients had their Neuraxial blockade before the minimum ASRA recommended time interval between the last anticoagulant dose and the Neuraxial procedure. Based on data from 2 reports, 52 parturients received Neuraxial Anesthesia without their low-molecular-weight heparin dose being discontinued during the intrapartum period. Although the very low level of evidence and high heterogeneity in these reports make it difficult to draw quantitative conclusions from this systematic review, it is encouraging that this comprehensive search did not identify a single case of SEH in an obstetric patient receiving thromboprophylaxis and Neuraxial Anesthesia. Analysis of large-scale registries (eg, the Anesthesia Incident Reporting System of the Anesthesia Quality Institute) with more granular clinical and pharmacological data is needed to assess the impact of these practice changes on obstetric SEH incidence. In the interim, optimal care of obstetric patients depends on multidisciplinary planning of anticoagulation dosing to facilitate Neuraxial Anesthesia and thoughtful weighing of the relative risks and benefits of providing versus withholding Neuraxial in favor of general Anesthesia.
Kanako Makito - One of the best experts on this subject based on the ideXlab platform.
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spinal epidural hematoma and abscess after Neuraxial Anesthesia a historical cohort study using the japanese diagnosis procedure combination database
Canadian Journal of Anaesthesia-journal Canadien D Anesthesie, 2020Co-Authors: Kanako Makito, Hideyuki Mouri, Hiroki Matsui, Nobuaki Michihata, Kiyohide Fushimi, Hideo YasunagaAbstract:BACKGROUND Spinal epidural hematoma and abscess are rare complications of Neuraxial Anesthesia but can cause severe neurologic deficits. The incidence of these complications vary widely in existing studies and the risk factors remain uncertain. We estimated the incidence of these complications and explored associations using a national inpatient database in Japan. METHODS Using Japanese Diagnosis Procedure Combination data on surgical inpatients who underwent Neuraxial Anesthesia from July 2010 to March 2017, we identified patients with spinal epidural hematoma and/or abscess. We investigated age, sex, Charlson comorbidity index, antithrombotic therapy, type of surgery, admission, and hospital for association with these complications. The incidences of spinal epidural hematoma and abscess were estimated separately, and a nested case-control study was performed to examine factors associated with these complications. RESULTS We identified 139 patients with spinal epidural hematoma and/or abscess among 3,833,620 surgical patients undergoing Neuraxial Anesthesia. The incidences of spinal epidural hematoma and abscess were 27 (95% confidence interval [CI], 22 to 32) and 10 (7 to 13) per one million patients, respectively. Spinal Anesthesia was associated with significantly fewer complications compared with epidural or combined spinal epidural Anesthesia (odds ratio, 0.15; 95% CI, 0.08 to 0.32). Antiplatelet agent (odds ratio, 0.49; 95% CI, 0.06 to 3.91) and anticoagulants (odds ratio, 1.65; 95% CI, 0.95 to 2.85) were not significantly associated with these complications. CONCLUSIONS This analysis identified the incidences of spinal epidural hematoma and/or abscess after Neuraxial Anesthesia. Additional large-scale studies are warranted to examine the incidences and factors associated with these complications.
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Spinal epidural hematoma and abscess after Neuraxial Anesthesia: a historical cohort study using the Japanese Diagnosis Procedure Combination database
Canadian Journal of Anesthesia Journal canadien d'anesthésie, 2020Co-Authors: Kanako Makito, Hideyuki Mouri, Hiroki Matsui, Nobuaki Michihata, Kiyohide Fushimi, Hideo YasunagaAbstract:Contexte Les hématomes et abcès périduraux sont des complications rares de l’anesthésie Neuraxiale qui peuvent toutefois provoquer des atteintes neurologiques graves. L’incidence de ces complications est très variable dans les études existantes et les facteurs de risque demeurent incertains. Nous avons estimé l’incidence de ces complications et exploré les associations en analysant une base de données nationale des patients hospitalisés au Japon. Méthode En nous fondant sur la base de données japonaise Diagnosis Procedure Combination (DPC – un système de paiement des soins de santé uniformisé) de juillet 2010 et mars 2017, nous avons identifié les patients chirurgicaux hospitalisés ayant reçu une anesthésie Neuraxiale et ayant souffert d’un hématome et/ou d’un abcès péridural. Nous avons examiné l’âge, le sexe, l’indice de comorbidité de Charlson, le traitement antithrombotique, le type de chirurgie, l’admission et l’établissement pour déterminer si ces facteurs étaient associés à ces complications. Les incidences d’hématomes et d’abcès périduraux rachidiens ont été séparément estimées, et une étude cas témoins imbriquée a été réalisée pour examiner les facteurs associés à ces complications. Résultats Nous avons identifié 139 patients ayant souffert d’un hématome et/ou d’un abcès péridural parmi les 3 833 620 patients chirurgicaux ayant reçu une anesthésie Neuraxiale. Les incidences d’hématome et d’abcès périduraux rachidiens étaient de 27 (intervalle de confiance [IC] 95 %, 22 à 32) et 10 (7 à 13) par million de patients, respectivement. La rachianesthésie était associée à un nombre significativement plus faible de complications comparativement à une anesthésie péridurale ou péridurale rachidienne combinée (rapport de cotes, 0,15; IC 95 %, 0,08 à 0,32). Aucune association significative n’a été observée entre les agents antiplaquettaires (rapport de cotes, 0,49; IC 95 %, 0,06 à 3,91) ou les anticoagulants (rapport de cotes, 1,65; IC 95 %, 0,95 à 2,85) et ces complications. Conclusion Cette analyse a identifié les incidences d’hématome et/ou d’abcès péridural après une anesthésie Neuraxiale. Des études supplémentaires de grande envergure sont nécessaires pour examiner les incidences et les facteurs associés à ces complications. Background Spinal epidural hematoma and abscess are rare complications of Neuraxial Anesthesia but can cause severe neurologic deficits. The incidence of these complications vary widely in existing studies and the risk factors remain uncertain. We estimated the incidence of these complications and explored associations using a national inpatient database in Japan. Methods Using Japanese Diagnosis Procedure Combination data on surgical inpatients who underwent Neuraxial Anesthesia from July 2010 to March 2017, we identified patients with spinal epidural hematoma and/or abscess. We investigated age, sex, Charlson comorbidity index, antithrombotic therapy, type of surgery, admission, and hospital for association with these complications. The incidences of spinal epidural hematoma and abscess were estimated separately, and a nested case-control study was performed to examine factors associated with these complications. Results We identified 139 patients with spinal epidural hematoma and/or abscess among 3,833,620 surgical patients undergoing Neuraxial Anesthesia. The incidences of spinal epidural hematoma and abscess were 27 (95% confidence interval [CI], 22 to 32) and 10 (7 to 13) per one million patients, respectively. Spinal Anesthesia was associated with significantly fewer complications compared with epidural or combined spinal epidural Anesthesia (odds ratio, 0.15; 95% CI, 0.08 to 0.32). Antiplatelet agent (odds ratio, 0.49; 95% CI, 0.06 to 3.91) and anticoagulants (odds ratio, 1.65; 95% CI, 0.95 to 2.85) were not significantly associated with these complications. Conclusions This analysis identified the incidences of spinal epidural hematoma and/or abscess after Neuraxial Anesthesia. Additional large-scale studies are warranted to examine the incidences and factors associated with these complications.
Terese T. Horlocker - One of the best experts on this subject based on the ideXlab platform.
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neurologic complications after Neuraxial Anesthesia or analgesia in patients with preexisting peripheral sensorimotor neuropathy or diabetic polyneuropathy
Anesthesia & Analgesia, 2006Co-Authors: James R Hebl, Sandra L Kopp, Darrell R Schroeder, Terese T. HorlockerAbstract:BACKGROUND: The risk of severe neurologic injury after Neuraxial blockade is extremely rare among the general population. However, patients with preexisting neural compromise may be at increased risk of further neurologic sequelae after Neuraxial Anesthesia or analgesia. METHODS: We retrospectively investigated 567 patients with a preexisting peripheral sensorimotor neuropathy or diabetic polyneuropathy who subsequently underwent Neuraxial Anesthesia or analgesia. Patient demographics, neurologic history, the indication and type of Neuraxial blockade, complications, and block outcome were collected for each patient. RESULTS: The majority of patients had chronically stable neurologic signs or symptoms at the time of block placement, with very few reporting progression of their symptoms within the last 6 mo. The type of Neuraxial technique included spinal Anesthesia in 325 (57%) patients, epidural Anesthesia or analgesia in 214 (38%) patients, continuous spinal Anesthesia in 24 (4%) patients, and a combined spinal-epidural technique in four (1%) patients. Overall, two (0.4%; 95% CI 0.1%-1.3%) patients experienced new or progressive postoperative neurologic deficits, in the setting of an uneventful Neuraxial technique. In these patients, the Neuraxial block may have contributed to the injury secondary to direct trauma or local anesthetic neurotoxicity around an already vulnerable nerve. Sixty-five (11.5%) technical complications occurred in 63 patients. The most common complication was unintentional elicitation of a paresthesia (7.6%), followed by traumatic (evidence of blood) needle placement (1.6%) and unplanned dural puncture (0.9%). There were no infectious or hematologic complications. CONCLUSIONS: The risk of severe postoperative neurologic dysfunction in patients with peripheral sensorimotor neuropathy or diabetic polyneuropathy undergoing Neuraxial Anesthesia or analgesia was found to be 0.4% (95% CI 0.1%-1.3%). Clinicians should be aware of this potentially high-risk subgroup of patients when developing and implementing a regional anesthetic care plan.
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Analgesia without paraplegia: Neuraxial Anesthesia and anticoagulation
2006Co-Authors: Terese T. HorlockerAbstract:An understanding of the mechanisms of blood coagulation, the pharmacologic properties of the anticoagulant and antiplatelet medications, and also the clinical studies involving patients undergoing central neural blockade while receiving these medications is paramount in reducing the risk of spinal hematoma in patients undergoing Neuraxial blockade. The actual incidence of neurologic dysfunction resulting from hemorrhagic complications associated with Neuraxial blockade is unknown; however, the incidence cited in the literature is estimated to be less than 1 in 150,000 epidural and less than 1 in 220,000 spinal anesthetics (Tryba, 1993). In a review of the literature between 1906 and 1994, Vandermeulen et al (Vandermeulen, 1994). reported 61 cases of spinal hematoma associated with epidural or spinal Anesthesia. Included were five parturients and four patients with anatomic abnormalities of the spine, such as spina bifid occulta, spinal ependymoma, and spinal angioma. A spinal anesthetic was performed in 15 cases, the remaining received an epidural technique. In 42 of the 61 patients (68%), the spinal hematoma occurred in patients with evidence of hemostatic abnormality. Twenty-five patients had received intravenous heparin (18 patients), subcutaneous heparin (3 patients), or LMWH (4 patients), while an additional five patients presumably received heparin during a vascular surgical procedure. In addition, 12 patients had evidence of coagulopathy or thrombocytopenia or were treated with antiplatelet medications (aspirin, indomethacin, ticlopidine), oral anticoagulants (phenprocoumone), thrombolytics (urokinase), or dextran 70 immediately before or after the Neuraxial anesthetic. Needle placement was reported as difficult in 25% of patients and/or bloody in 25% of patients. Multiple punctures were reported in 20% of patients. Therefore, in 87% of patients, a hemostatic abnormality or traumatic/difficult needle placement was present. More than one Analgesia without paraplegia: Neuraxial Anesthesia and anticoagulation
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Neurologic complications after Neuraxial Anesthesia or analgesia in patients with preexisting peripheral sensorimotor neuropathy or diabetic polyneuropathy.
Anesthesia & Analgesia, 2006Co-Authors: James R Hebl, Sandra L Kopp, Darrell R Schroeder, Terese T. HorlockerAbstract:BACKGROUND:The risk of severe neurologic injury after Neuraxial blockade is extremely rare among the general population. However, patients with preexisting neural compromise may be at increased risk of further neurologic sequelae after Neuraxial Anesthesia or analgesia.METHODS:We retrospectively inv
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cardiac arrest during Neuraxial Anesthesia frequency and predisposing factors associated with survival
Anesthesia & Analgesia, 2005Co-Authors: Sandra L Kopp, Terese T. Horlocker, Mary E Warner, James R Hebl, Claude A Vachon, Darrell R Schroeder, Allan B Gould, Juraj SprungAbstract:: The frequency and predisposing factors associated with cardiac arrest during Neuraxial Anesthesia remain undefined, and the survival outcome data are contradictory. In this retrospective study, we evaluated the frequency of cardiac arrest, as well as the association of preexisting medical conditions and periarrest events with survival after cardiac arrest during Neuraxial Anesthesia between 1983 and 2002. To assess whether survival after cardiac arrest differs for patients who arrest during Neuraxial versus general Anesthesia, data were also obtained for patients who experienced cardiac arrest under general Anesthesia during similar surgical procedures during the same time interval. Over the 20-yr study period at the Mayo Clinic, there were 26 cardiac arrests during Neuraxial blockade and 29 during general Anesthesia. The overall frequency of cardiac arrest during Neuraxial Anesthesia for 1988 to 2002 was 1.8 per 10,000 patients, with more arrests in patients receiving spinal versus epidural Anesthesia (2.9 versus 0.9 per 10,000; P = 0.041). In 14 (54%) of the 26 patients who arrested during a Neuraxial technique, the anesthetic contributed directly to the arrest (high sympathectomy or respiratory depression after sedative administration), whereas in 12 (46%) patients, the arrest was associated with a specific surgical event (cementing of joint components, spermatic cord manipulation, reaming of the femur, and rupture of amniotic membranes). Patients who arrested during general Anesthesia had a higher ASA classification than those who arrested during a Neuraxial block (P = 0.031). Hospital survival was significantly improved for patients who arrested during Neuraxial Anesthesia versus general Anesthesia (65% vs 31%; P = 0.013). The association of improved survival with Neuraxial Anesthesia remained statistically significant after adjusting for all patient/procedural characteristics, with the exception of ASA classification and emergency procedures. We conclude that a cardiac arrest during Neuraxial Anesthesia is associated with an equal or better likelihood of survival than a cardiac arrest during general Anesthesia.
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ANTICOAGULATION AND Neuraxial Anesthesia
Anesthesiology Clinics of North America, 1999Co-Authors: Terese T. HorlockerAbstract:Spinal hematoma is a rare and potentially catastrophic complication of spinal or epidural Anesthesia. The actual incidence of neurologic dysfunction resulting from hemorrhagic complications associated with central neural blockade is unknown; however, the incidence cited in the literature is estimated to be less than 1 in 150,000 epidural and less than 1 in 220,000 spinal anesthetics. 39 Hemorrhage into the spinal canal most commonly occurs in the epidural space because of the prominent epidural venous plexus. Although hemorrhagic complications can occur after virtually all regional anesthetic techniques, bleeding into the spinal canal is perhaps the most serious hemorrhagic complication associated with regional Anesthesia because the spinal canal is a concealed and nonexpandable space. Spinal cord compression from spinal hematoma may result in neurologic ischemia and paraplegia. Spinal hematoma may occur from vascular trauma from needle or catheter placement into the subarachnoid or epidural space. However, it may also occur in association with neoplastic disease or preexisting vascular abnormalities. Of special interest to the anesthesiologist are those spinal hematomas that have occurred spontaneously with or without the presence of antiplatelet or anticoagulation therapy. Over 100 spontaneous epidural hematomas have been reported, 25% of which are associated with anticoagulation therapy. 38 In a review of the literature between 1906 and 1994, Vandermeulen et al 41 reported 61 cases of spinal hematoma associated with epidural or spinal Anesthesia. In 42 of the 61 patients (69%), the spinal hematomas associated with central neural blockade occurred in patients with evidence of hemostatic abnormality. Twenty-five of the patients had received intravenous or subcutaneous heparin, while an additional five patients were presumably administered heparin as they were undergoing a vascular surgical procedure. In addition, 12 patients had evidence of coagulopathy or thrombocytopenia or were treated with antiplatelet medications (aspirin, indomethacin, ticlopidine), oral anticoagulants (phenprocoumone), thrombolytics (urokinase), or dextran. Seventy were treated immediately before or after the spinal or epidural anesthetic. Needle and catheter placement were reported to be difficult or bloody in 15 (25%) patients. Thus, in 53 of the 61 cases (87%), either a clotting abnormality or needle placement difficulty was present. Neurologic compromise presented as progression of sensory of motor block or bowel/bladder dysfunction, not severe radicular back pain. Importantly, although only 48% of patients had partial or good neurologic recovery, spinal cord ischemia tended to be reversible in patients who underwent laminectomy within 8 hours of onset of neurologic dysfunction (Table 1). In order to reduce the risk of spinal hematoma associated with central neural blockade, it is necessary to understand the mechanisms of blood coagulation, the pharmacologic properties of the anticoagulant and antiplatelet medications, and also the clinical studies involving patients undergoing central neural blockade while receiving these medications. Recommendations for regional anesthetic management follow the consensus statements on Neuraxial Anesthesia and Anticoagulation published by the American Society of Regional Anesthesia. 9,18,21,34,40 Although this article will deal mainly with continuous techniques of major conduction blocks and anticoagulants, the same principles apply to all regional anesthetic techniques.