Complications of neuraxial blockade

Direct visualization transversus abdominis plane blocks offer superior pain control compared to ultrasound guided blocks following open posterior component separation hernia repairs

PURPOSE

Transversus abdominis plane (TAP) blockade with long-acting anesthetic can be used during open ventral hernia repair (VHR) with posterior component separation (PCS). TAP block can be performed under ultrasound guidance (US-TAP) or under direct visualization (DV-TAP). We hypothesized that US-TAP and DV-TAP provide equivalent postoperative analgesia following open VHR.

METHODS

A retrospective review of patients undergoing open VHR with PCS who received TAP blocks with 266 mg of liposomal bupivacaine was performed. Data included demographics, comorbidities, length of stay (LOS), average postoperative day (POD) pain scores, and narcotic requirements (normalized to mg oral morphine). Statistical analysis utilized Student's t test and Fisher's exact test.

RESULTS

Thirty-nine patients were identified (22 DV-TAP). There were no differences between the groups with respect to demographics, comorbidities, pre-operative pain medication usage (narcotic and non-narcotic) or herniorrhaphy-related data. The average POD0 pain score was lower for the DV-TAP group (2.35 vs 4.18; p = 0.019). Narcotic requirements on POD0 (48.0 vs 103.76 mg; p = 0.02), POD1 (128.45 vs 273.82 mg; p = 0.03), POD4 (54.29 vs 160.75 mg; p = 0.042), and during the complete hospitalization (408.52 vs 860.92 mg; p = 0.013) were lower in the DV-TAP group. There were no differences between initiation of diet or LOS. During the study, no changes were made to the VHR enhanced recovery pathway.

CONCLUSIONS

DV-TAP blocks appear to provide superior analgesia in the immediate postoperative period. To achieve similar post-operative pain scores, patients in the US-TAP group required significantly more narcotic administration during their hospitalization. The study highlights DV-TAP as a valuable addition to VHR recovery pathways.

Lumbar punctures in thrombocytopenic children with cancer

INTRODUCTION

Lumbar punctures (LP) in patients presenting thrombocytopenia are linked to the possibility of bleeding and spinal hematomas. The minimum platelet count required for the safe performance of spinal procedures is still under discussion. Children with some oncology diseases require routinely lumbar punctures; such patients often present thrombocytopenia, making this group an ideal population to study the association between lumbar puncture in thrombocytopenic patients and complications.

OBJECTIVES

To determine the platelet count of oncology children undergone lumbar punctures and the occurrence of spinal hematomas.

METHOD

Observational longitudinal study. It included a retrospective analysis of electronic medical records of oncology patients submitted to LP for intrathecal chemotherapy between January 2004 and October 2011, carried out at the 'Instituto de Medicina Integral Prof. Fernando Figueira (IMIP)', Recife, Brazil.

RESULTS

We evaluated 9088 lumbar punctures performed in 440 patients. The platelet count distribution before lumbar punctures was as follows: 25 punctures had zero to 10,000 platelets per mm(3), 67 punctures had between 10,000 and 20,000 platelets per mm(3), 88 had between 20,000 and 30,000 platelets per mm(3), 92 punctures had between 30,000 and 40,000 platelets per mm(3), 107 punctures had between 40,000 and 50,000 platelets per mm(3), and 729 punctures had between 50,000 and 100,000 platelets per mm(3). In this series, the incidence of bloody tap was 16.9% (1112 lumbar punctures of 6552 had more than ten erythrocytes). No complications were observed.

CONCLUSIONS

Even in thrombocytopenic patient, an epidural hematoma would be a relatively rare complication following lumbar puncture. Despite the large number of punctures performed on patients with platelet counts below 100,000 mm(-3) (n = 1108), further studies are necessary in order to determine a lower safe platelet count threshold for the performance of lumbar punctures in healthy patients undergoing neuraxial anesthesia.

Caesarean delivery complicated by unintentional subdural block and conversion disorder

Combined spinal epidural (CSE) can provide excellent labor analgesia. Subdural block is also a potential but rare complication of attempted epidural placement during a CSE procedure, which may present as a block that is usually patchy in nature, with a component of sensory and/or motor deficit and a variable duration of action. In addition, a conversion disorder or a functional neurological disorder has been described with epidural and spinal anesthesia in obstetric patients. In this clinical report, we describe a 33-year-old G4P3 at 40 weeks gestation that received an unintentional subdural block as part of her labor analgesia and after an uneventful caesarean delivery presented with a conversion disorder. The rarity of the association between a subdural block and a conversion disorder complicated by the fact that the neurological deficit produced by the subdural block and that produced by a conversion disorder are similar in distribution made the clinical presentation and diagnosis a challenge for the obstetric anesthesia team. A functional neurological disorder of this nature complicating a subdural block in an obstetric anesthesia clinical practice has not been described so far.

Epidural abscess after multiple lumbar punctures for labour epidural catheter placement

Epidural catheterization is routinely used by anaesthesiologists to provide labour and post-operative analgesia. In most cases, catheter placement is without serious side effects and uneventful. However, epidural abscess is a rare complication that may result in severe morbidity. We present a case of epidural abscess after labour epidural catheter placement in a healthy 36-year-old female who presented on post-partum d 10 with complaints of fever and back pain. She was treated with intravenous antibiotics and fully recovered.

Local infiltration analgesia in TKA patients reduces length of stay and postoperative pain scores

Numerous postoperative pain protocols exist for patients undergoing total knee arthroplasty (TKA). We compared the length of stay, early range of motion (ROM), and pain scores of a control group with a femoral nerve block to those of a group with femoral nerve block and local infiltration analgesia following TKA. In a consecutive series of patients undergoing primary TKA at a Veteran's Administration hospital, 40 patients (40 TKAs) who had local infiltration analgesia were compared to a historical group of 43 patients (43 TKAs) who had a long-acting femoral nerve block without local infiltration analgesia. Local infiltration analgesia consisted of intraoperative injection of 150 mL of 300 mg ropivacaine, 30 mg ketorolac, and 500 μg epinephrine using 50 mL into each of 3 areas: (1) posterior capsule, (2) medial and lateral capsule, and (3) anterior capsule and subcutaneous tissues. A 17-gauge intra-articular catheter was used to inject an additional 100 mg of ropivacaine on postoperative day 1. The control group had a single-shot femoral nerve block using 150 mg of ropivacaine with epinephrine. Mean length of stay for the local infiltration analgesia group compared to controls was 3.2±1.4 days vs 3.8±1.6 days, respectively (P=.03). No significant differences existed in average ROM (6 weeks), discharge hematocrit, transfusions, and temperature. Mean pain scores were lower in the local infiltration analgesia group on postoperative day 1 (P=.04), but not on postoperative day 2 or 3. Maximum visual analog scale scores (P<.01) were reduced in the local infiltration analgesia group. Our early experience with local infiltration analgesia demonstrated a significantly reduced length of stay due to decreased postoperative pain.

Safety of amide local anesthetics: new trends

IMPORTANCE OF THE FIELD

Local anesthetics have become one of the most common drugs used in daily practice worldwide. Neurologic and cardiovascular events are the most frequent adverse reactions related to local anesthetics use. Recently, new trends have been developed on this topic.

AREAS COVERED IN THIS REVIEW

We performed an overview of the data available so far on local anesthetics adverse reactions. Relevant literature was identified using PubMed search of articles published up to November 2009, including experimental studies, case reports or clinical studies when available. Search terms included: 'local anaesthetics', 'adverse drug reaction', 'pharmacovigilance' and 'complication'.

WHAT THE READER WILL GAIN

Neurologic, cardiovascular and allergic reactions remain the most frequent adverse drug reactions related to local anesthetics in the literature. Studies based on pharmacovigilance systems have highlighted the frequency of adverse reactions little known until now, such as failure of block. Lipid emulsions are included into algorithm for cardiac resuscitation. Recent studies have demonstrated the myotoxicity and chondrotoxic effects of long-acting local anesthetics.

TAKE HOME MESSAGE

Physicians must keep in mind all these adverse reactions to better prevent their occurrence and give the most appropriate treatment.

Can epidural anesthesia and warfarin be coadministered?

Epidural hypotensive anesthesia can, in addition to imparting numerous intraoperative benefits, provide excellent postoperative pain control for patients having joint arthroplasties. However, because of the risk of epidural hematoma, epidural anesthesia is not coadministered with anticoagulation in some centers. We retrospectively ascertained, by chart review, the incidence of epidural hematoma in 11,235 patients having 12,991 knee arthroplasties at our institution who received oral anticoagulation and epidural anesthesia for their surgery. Warfarin was administered on the day of surgery. With the exception of 212 patients, the epidural catheter was removed within 48 hours of surgery. Based on clinical examinations, we detected no epidural hematomas. For 1030 patients (1038 knees) whose charts were reviewed in detail, the mean international normalized ratio at the time of removal of the epidural catheter was 1.54 (range, 0.93-4.25). We identified no other complications related to the coadministration of epidural anesthesia and warfarin. Although administration of epidural anesthesia in patients with coagulopathy can be detrimental, we recognized no cases of epidural hematoma causing neurologic symptoms in patients receiving controlled oral anticoagulation after total knee arthroplasty.

[Spinal epidural abscess after long-term epidural catheterization]

This case report describes a 63-year-old male patient with considerably impaired postoperative wound healing in the region of the lower extremities. After initial drug therapy for the pain was ineffectual, the patient was treated repeatedly through an epidural catheter. In the further course, an extensive spinal epidural abscess was diagnosed as an incidental finding without neurological symptoms. After taking into consideration the patient's age and the risk factors present as well as inclusion of the subspecialties involved for an interdisciplinary assessment, the patient was successfully treated with a conservative approach. Our contribution concludes with a detailed discussion and comparison of the literature.

Intraparenchymal migration of an intrathecal catheter three years after implantation

Intrathecal drug administration using implanted catheter and pump systems has been used in routine clinical practice for more than 20 years to treat chronic refractory pain or spasticity. Complications associated with the use of these systems include drug related adverse events as well as technical problems, most of which are related either to the catheter or the procedure. Although traumatic neural damage is exceedingly rare it is usually associated with significant neurological impairment. We present a case of asymptomatic intraspinal migration of an intrathecal catheter three years after an uneventful implantation. To the best of our knowledge, this complication has never been reported before.

Intrinsic Spinal Cord Catheter Placement: Implications of New Intractable Pain in a Patient with a Spinal Cord Injury

We present a case of new intractable flank pain after intrathecal infusion system placement in a 45-yr-old man with a history of a T12 spinal cord injury with dysesthetic leg pain. Pain after intrathecal infusion system placement was evaluated by magnetic resonance imaging and the catheter was found to be intraparenchymal. The patient was treated by cessation of infusion and surgical removal of the system. Before surgical removal, the pump was turned off and the patient's flank pain resolved. Increased vigilance is warranted when caring for paraplegic patients. When new pain persists, intrathecal medication tapering should be considered.