Complications in ob anesthesia,especiallly neurological complications.

1. Complications in obstetric
anesthesia
Complications in obstetric
anesthesia
C.MelloniC.Melloni
Servizio di Anestesia e RianimazioneServizio di Anestesia e Rianimazione
Ospedale di Faenza(RA)Ospedale di Faenza(RA)

2. 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
Entrata in vigore della nuova

3. 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

4. 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

5. 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 of
gastric content
Aspir of
gastric content
cardioreso
arrest
cardioreso
arrest
N.YN.Y
12 GA12 GA
Aspir of gastric
content
Aspir of gastric
content
cardioreso
arst
cardioreso
arst
cardiac
arrest
cardiac
arrest
1 RA(bupi
i.v .)
1 RA(bupi
i.v .)

6. Patterns of maternal mortality associated with
anesthesia
Patterns of maternal mortality associated with
anesthesia
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 kinked
ETT
7 from GA:5 error in OTI;1 aspiration,1 kinked
ETT
1 from reg;cardiovasc collpase under epidural
block in a patient with aortic insuff.
1 from reg;cardiovasc collpase under epidural
block in a patient with aortic insuff.

7. 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.

8. 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

9. Mallampati Score changes during pregnancy
(Piklington et al,BJA 1995;74:638)
0
10
20
30
40
50
60
%
1 2 3 4
12-set
38 sett
score

10. 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 gen
C/S (Pilk)
C/S (Durban)
ost (Carli)

11. 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

12. Unnecessary GA
• Inadequate patient education
• Surgeons habits
• Late call
• Surpassed indications:
– preeclampsia
– placenta praevia
– fever
– Cardiac disease

13. 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……...

14. 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

15. 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.

16. Estimates from CDC USAEstimates from CDC USA
1979-841979-84
Cs 19%Cs 19%
GA 41%,REG 55%GA 41%,REG 55%
1990-921990-92
CS 24%CS 24%
GA 16%,REG 84%GA 16%,REG 84%
MortalityMortality 82% from CS82% from CS

17. Hawkins JL,Koonin LM,Palmer SK,Gibbs
CP.Anesthesia related deaths during obstetric
delivery in the United States(Anesthesiology
1997;86:277-84).
0
2
4
6
8
10
12
14
16
18
%
79-81 82-84 85-87 88-90
num.tot=129
GA
REG
unknown
sedation

18. 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

19. From CDC USA fatalities :GA vs reg.
• GA 2.3 > reg (1979—1984)
• GA 16.7 > reg ( 1985—1990).

20. Complication rate AG * C/S: CDC USA
• Deaths:
• 20.0/million GA ( 1979—1984)
• 32.3 /million (1985—1990)

21. Mortality ( CS )in Reg anest
CDC USA
• 8.6 /million of Reg anest.( 1979—1984)
• 1.9 /million ( 1985—1990).

22. Chadwick,HS,Posner,K,Kaplan,RA,Ward,RJ,Ch
eney 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!

23. Damaging events in obs vs nonobs claims
0
2
4
6
8
10
12
14
%
ob nonob
inadeq.ventilation
difficult intub
pulm.aspir.
esoph.intub
bronchospasm
inadeq.FiO2
airways obstruct.
estubaz prematura
convuls
equipment problems
drug mistake
fluid mistake
blood loss
trans.mistake
*
*
*
Probl.resp
Probl cardiocirc

24. Maternal damage:CS vs vaginal delivery
0
5
10
15
20
25
%
CS vag
maternal death
neonatal cerebral damage
headache
neonatal death
pain during anesth.
neural damage
cerebral damage pt)
emotional distress
dorsalgia
*

25. Obstetrical claims;reg vs ga
0
5
10
15
20
25
30
35
40
45
%
reg GA
maternal death
neonatal cerebral damage
headache
neonatal death
pain during anesth.
neural damage
cerebral damage pt)
emotional distress
dorsalgia
*
*
*
*

26. Neonatal damageNeonatal damage
pathogenesispathogenesis
45% :anesthesia related45% :anesthesia related
4 GA :1 bronchospasm,1 oesophag.intub,1 pulm.aspir,1
anesth,delay; polm,1 anesth delay) ,
13 reg:,9 convulsafter intravasc adm;1 eclampsia,1 medical
delay,3 high spinal
4 GA :1 bronchospasm,1 oesophag.intub,1 pulm.aspir,1
anesth,delay; polm,1 anesth delay) ,
13 reg:,9 convulsafter intravasc adm;1 eclampsia,1 medical
delay,3 high spinal
37% : obstetrical or congenital problems37% : obstetrical or congenital problems
13% resuscitation problems13% resuscitation problems

27. Pulmonary inhalationPulmonary inhalation
8% ob claims vs 2% non ob claims8% ob claims vs 2% non ob claims
50% associated with difficult intub;oesophageal or
inadequate ventilation
50% associated with difficult intub;oesophageal or
inadequate 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 by
anesth--hypoxia
Tetrac 20 mg and 4 administered by the obs-resp insuff-ETT after 6-7 min by
anesth--hypoxia

28. ConvulsionsConvulsions
10% in ob claims vs 1% non ob claims10% in ob claims vs 1% non ob claims
83% associated with severe neurological damage ,maternal
and/or neonatal death
83% associated with severe neurological damage ,maternal
and/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

29. 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

30. 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.

31. 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.
0
5
10
15
20
25
30
35
40
%
minore(0-3) magg(4-6) invalidità(7-
8)
morte(9)
ob
non ob

32. Payment data in $
reg gen
not paid(%) 32 38 43 27
paid (%) 59 53 48 63
median payment 85000 203000 91000 225000
payment angerange 15000-6mil 675000-5.4 mil 675-2.5 mil750-5.4 mil
GA paid 63% vs 48%
reg.

33. 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

34. Conclusions from the closed
claims
Conclusions from the closed
claims
HeadacheHeadache
3rd complaint3rd complaint
payment in 56%payment in 56%

35. 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..)

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

37. Scott DB, Hibbard BM. Serious non-fatal complications
associated with extradural block in obstetric practice.
Scott DB, Hibbard BM. Serious non-fatal complications
associated 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 with
success)
1 abscess & 1 subdural hematoma (evacuated with
success)

38. Scott DB, Tunstall ME. Serious complications
associated with epidural/spinal blockade in obstetrics.
Scott DB, Tunstall ME. Serious complications
associated 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

39. Holdcroft A, Gibberd FB, Hargrove RL, Hawkins DF, Dellaportas CI. Neurological complications
associated with pregnancy. British Journal of Anaesthesia 1995; 75:522-526.
Holdcroft A, Gibberd FB, Hargrove RL, Hawkins DF, Dellaportas CI. Neurological complications
associated 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(spontaneous
delivery under nitrous oxide analgesia of a large baby via a small pelvis)
Bell,cervical,L5 disc prolapse,preexisting sciatica,foot drop(spontaneous
delivery under nitrous oxide analgesia of a large baby via a small pelvis)

40. Holdcroft et al. Neurological complications associated with
pregnancy. 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 ,1
meningitis
2 from space occup.lesions,1 mult.scler.,1 diabetic ,1
meningitis
2 dorsal pain2 dorsal pain
1 paresth.of a neural root dstrib.1 paresth.of a neural root dstrib.

41. Neurological complications associated with Reg
anesth
Neurological complications associated with Reg
anesth
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...)

42. Why do we have problems with
obstetric analgesia
Why do we have problems with
obstetric analgesia
joy/damagejoy/damage
anesthesiologist
visibility
anesthesiologist
visibility
obstetricians
"scaricabarile"
obstetricians
"scaricabarile"
invisibility
the fetal
head
invisibility
the fetal
head
preference for
regional
anesthesia
preference for
regional
anesthesia

43. 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……..

44. Etiology of neurological sequelaeEtiology of neurological sequelae
unrelated 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,mult
sclerosis,postinfectious neuritis....
exacerbation of collagen dis.,vascular,polyneuropathy,mult
sclerosis,postinfectious neuritis....

45. Etiology of neurological complicationsEtiology of neurological complications
related 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 se
direct trauma by needle,catheter,injection...direct trauma by needle,catheter,injection...

46. 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

47. 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

48. 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

49. NeurotoxicityNeurotoxicity
ChloroprocaineChloroprocaine
5% lidocaine5% lidocaine
TRI....TRI....

50. TRITRI
uneventful 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

51. cauda equina syndromecauda equina syndrome
tox.of LA spinal anesthetics?tox.of LA spinal anesthetics?
paraparesis,paraplegia,numbness
in the saddle area,incompretence
of bladder and anal sphincter
paraparesis,paraplegia,numbness
in the saddle area,incompretence
of bladder and anal sphincter
permanent deficitspermanent deficits

52. 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!

53. 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

54. 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%

55. Paresthesias and motor dysfunction after labor and
delivery
Incidence of paresthesias& motor
dysfunction:18.9/10.000(45 cases)
0
5
10
15
20
25
30
35
40
/10.000
multipar
primipar
vag spont
forceps,vacuum
no analg
analg. Inalat
epid only
GA
* *
* *

56. 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………...

57. 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

58. 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)

59. • Any persistent postspinal
headache or recurrence of it
should alert the
anesthesiologist………
» LOO IJOA 2000

60. 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)

61. 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

62. Petroclinoid ligament

64. 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..

65. Etiology of paralysisEtiology of paralysis
coexisting
disease
coexisting
disease
iatrogeniciatrogenic
intraspinal
sepsis
intraspinal
sepsis
parturition
process
parturition
process
visibility of reg anesth....visibility of reg anesth....

66. Visibility of reg anesth…..

67. Nerve traumaNerve trauma
Auroy,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

68. Foetal head descent

69. Maternal obstetric palsiesMaternal obstetric palsies
Bademosi,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)

70. 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
CSE
SSS
all

71. Damage to the conus medullaris
following spinal anesthesia
Damage to the conus medullaris
following 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

72. Position of the tip of the conus medullaris as referred to
the adjacent third of the vertebral body or disc space.
Position of the tip of the conus medullaris as referred to
the 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 5757 11,3111,31
L1M3L1M3 6868 13,6913,69
L1I3L1I3 127127 25,225,2
L1/L2L1/L2 8282 16,2716,27
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

75. The level of PL was falsely evaluated in 62% of
cases.puncture performed 1-2 interspaces higher than
assumed…(Van Gassel 1993)

76. 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

77. Inability to identify correctly the
intervertebral spaces
Inability to identify correctly the
intervertebral spaces
"provare per credere""provare per credere"
Correct identificationCorrect identification only 29% of casesonly 29% of cases
actual interspaceactual interspace
1-4 interspaces higher
than assumed in 68% of
cases
1-4 interspaces higher
than assumed in 68% of
cases
it cannot be recommended to insert the
spinal needle higher than L3-L4 at the
highest.
it cannot be recommended to insert the
spinal needle higher than L3-L4 at the
highest.
Reynolds Anesthesia
2000
Reynolds Anesthesia
2000

78. In pregnant patients at term cephalic pelvic tilt
may further displace the apparent intercristal
line in a cephalad direction...:

79. 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 WCA
2000)
45 cases in Medline(Schneidr,com WCA
2000)

80. 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.

81. Epidural abscessEpidural abscess
Clinical 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
Aggressive surgical managem ent(drainage???
Aggressive surgical management(drainage???
Blood cult(25
MRI gadol en

82. MeningitisMeningitis
bacterialbacterial
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.

83. MeningitisMeningitis
incidence 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?
????

84. Prevention of epi/spinal infectionsPrevention of epi/spinal infections
alwaysalways
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

85. Spinal epidural haematomaSpinal epidural haematoma
reluctance 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

86. Spinal haematoma in absence of
coagulopathy or thromboprophylaxis
Spinal haematoma in absence of
coagulopathy 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

87. Risk of spinal / epidural haematomaRisk of spinal / epidural haematoma
data 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

88. 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

89. 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

90. 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