Local anaesthetics are routinely used for several indications, but despite local administration their use may lead to systemic toxicity. The symptoms include numbness of the tongue, dizziness, tinnitus, visual disturbances, muscle spasms, convulsions, coma, and respiratory and cardiac arrest. Recently, an intravenous lipid emulsion was reported to act as a novel potential antidote for systemic toxicity due to local anaesthetics. We describe the application of this lipid emulsion in a 27-year-old patient with generalized seizures and coma due to local anaesthetic toxicity. She recovered quickly and was responsive again 10 minutes after the intravenous administration of the lipid emulsion.
Background The clinical use of epidural analgesia has changed over past decades. Minimally invasive surgery and emergence of alternative analgesic techniques have led to an overall decline in its use. In addition, there is increasing awareness of the patient‐specific risks for complications such as spinal haematoma and abscess. Local guidelines for management of severe neurological complications during or after epidural analgesia, ie, “epidural alert systems”, have been introduced in hospitals to coordinate and potentially streamline early diagnosis and treatment. How widely such protocols have been implemented in daily practice is unknown. Methods We conducted a survey to analyse trends in practice, key indications, safety measures, safety reporting, and management of complications of epidural analgesia in the Netherlands. Data were gathered using a web‐based questionnaire and analysed using descriptive statistics. Results Questionnaires from 85 of all 94 Dutch hospitals performing epidural analgesia were collected and analysed, a 90% response rate. Fifty‐five percent reported a trend towards decreased use of perioperative epidural analgesia, while 68% reported increasing use of epidural analgesia for labour. Reported key indications for epidural analgesia were thoracotomy, upper abdominal laparotomy, and abdominal cancer debulking. An epidural alert system for neurological complications of epidural analgesia was available in 45% of hospitals. Conclusions This national audit concerning use and safety of epidural analgesia demonstrates that a minority of Dutch hospitals have procedures to manage suspected neurological complications of epidural analgesia, whereas in the remaining hospitals responsibilities and timelines for management of epidural emergencies are determined on an ad hoc basis.
( Br J Anaesth . 2018;120:693–704) Incidences of spinal hematoma or abscess after central neuraxial block (CNB) are estimated to be low, with the former being 1:154,730 and the latter being so rare, it could not even be calculated in a major 2016 study. Because of the rarity, there is no evidence on which to base recommendations for management strategies. However, these adverse events could result in permanent injury for patients, with the incidence of paraplegia or death being 1.8 per 100,000 patients. Therefore, the authors of the present study reviewed all cases reported regarding spinal hematomas or abscesses after CNB, identified potential factors that may predispose patients to these adverse outcomes, and predicted persistent neurological damage.
( Eur J Anaesthesiol . 2020;37:743–751) Current anesthesia practice often involves neuraxial techniques such as spinal anesthesia and epidural analgesia. The leading anesthetic technique for cesarean delivery remains spinal anesthesia, while chronic pain treatments include spinal cord stimulators, epidural injections, and intrathecal drug delivery systems. The rarest but most feared complication of these techniques is injury to the spinal cord via neuraxial abscess or hematoma, but possible other complications include medication errors, meningitis, and even direct nerve injury. The primary aim of this study was to identify possible preventable causes of hematoma and abscess, meningitis, and other serious adverse outcomes following neuraxial procedures by analyzing claims databases in two countries: The Anesthesia Closed Claims Project database in the USA, and the Netherlands’ two largest medical insurance companies’ databases.
( Acta Anaesthesiol Scand . 2018;62:1466–1472) There is a trend to move away from neuraxial blocks in favor of truncal blocks, peripheral nerve blocks, and local anesthetic wound infiltration in the Netherlands. Furthermore, recent epidural “alert systems” have been introduced, meant to aid in the early detection of spinal hematoma or abscess after neuraxial anesthesia. However, these changes have not been investigated on a national level. The authors of the present study thus quantified trends in the practice of epidural analgesia and assessed the extent to which these epidural alert systems have been introduced in clinical practice.
BACKGROUND Severe complications after neuraxial anaesthesia are rare but potentially devastating. OBJECTIVE We aimed to identify characteristics and preventable causes of haematoma, abscess or meningitis after neuraxial anaesthesia. DESIGN Observational study, closed claims analysis. SETTING Closed anaesthesia malpractice claims from the USA and the Netherlands were examined from 2007 until 2017. PATIENTS Claims of patients with haematoma ( n = 41), abscess ( n = 18) or meningitis ( n = 14) associated with neuraxial anaesthesia for labour, acute and chronic pain that initiated and closed between 2007 and 2017 were included. There were no exclusions. MAIN OUTCOME MEASURES We analysed potential preventable causes in patient-related, neuraxial procedure-related, treatment-related and legal characteristics of these complications. RESULTS Patients experiencing spinal haematoma were predominantly above 60 years of age and using antihaemostatic medication, whereas patients with abscess or meningitis were middle-aged, relatively healthy and more often involved in emergency interventions. Potential preventable causes of unfavourable sequelae constituted errors in timing/prescription of antihaemostatic medication (10 claims, 14%), unsterile procedures ( n = 10, 14%) and delay in diagnosis/treatment of the complication ( n = 18, 25%). The number of claims resulting in payment was similar between countries (USA n = 15, 38% vs. the Netherlands n = 17, 52%; P = 0.25). The median indemnity payment, which the patient received varied widely between the USA (€285 488, n = 14) and the Netherlands (€31 031, n = 17) ( P = 0.004). However, the considerable differences in legal systems and administration of expenses between countries may make meaningful comparison of indemnity payments inappropriate. CONCLUSIONS Claims of spinal haematoma were often related to errors in antihaemostatic medication and delay in diagnosis and/or treatment. Spinal abscess claims were related to emergency interventions and lack of sterility. We wish to highlight these potential preventable causes, both when performing the neuraxial procedure and during postprocedural care of patients.
