Neurological complications following central neuraxial blocks: are there predictive factors?:

Dental deaths in Italy as reported by online press articles

OBJECTIVES

Mortality on the dental chair is a rare and underreported event. This study aimed to identify all deaths that occurred during dental procedures in Italy.

METHODS

We searched PubMed/Medline, Scopus, and Internet archives looking for patients who died before, during, or after a dental procedure in Italy from 1990 to 2019.

RESULTS

All the 36 identified fatal events were reported by national or regional newspapers, and none was reported by scientific databases. Interestingly, no cases regarding patients ≤16 years old were found and there was no variation in the number of reported deaths over the years. Most of the cases (n = 29) occurred in out-of-hospital private dental offices. Tooth extraction represented the most frequent culprit operation (39%), while myocardial infarction (28%) was the leading cause of death, followed by cardiac arrest (25%), allergies (11%), and infections (8%). In four cases, death was preprocedural, in 10 intraprocedural and in 21 postprocedural. In 17 cases, a temporal association between injection of anesthesia/sedation and death was observed.

CONCLUSION

This is the first report on Italian dental procedure-related deaths. Most of these deaths were only temporally associated with a dental procedure and could not to be attributed to malpractice.

A survey of international antisepsis procedures for neuraxial catheterisation in labour

BACKGROUND

Neuraxial analgesia during labour is a mainstay of anaesthetic practice globally. Despite the potential for significant neurological and infectious complications, international antisepsis practices for neuraxial anaesthesia vary widely.

AIMS

The primary aim of this study was to clarify international antisepsis practices prior to neuraxial analgesia in labour. The secondary aim was to determine an approximate international incidence of neuraxial infections and neurological complications secondary to neuraxial analgesia techniques in labour.

MATERIALS AND METHODS

Heads of Departments of Anaesthesiology were invited to complete an online questionnaire exploring antisepsis practices and complications of neuraxial catheterisation. Data from 151 institutions in 13 countries were collected over 11months.

RESULTS

Data were collected for an estimated 6008540 deliveries and 3770800 neuraxial catheterisations. The average annual birth rate per institution was 3979 births, with an average of 2497 neuraxial catheterizations (representing 62.8% of deliveries). Forty-nine percent of responders reported always wearing sterile gowns for the procedure, whereas 47.7% never wear gowns. Chlorhexidine was used by 88.1% of those surveyed, and 96.7% always wore facemasks. Thirty-four percent of institutions reported infectious complications over a 10-year period. Ninety neuraxial infections were estimated, giving an approximate incidence of 1:41898 catheterisations (2.39 infections per 100000 catheterisations). A total of 202 neurological complications were reported, with an approximate incidence of 1:18667 catheterisations (5.36 neurological complications per 100000 catheterisations).

CONCLUSION

The survey demonstrated marked variation in aseptic practice between both responding centres and countries. The incidence of infectious and neurological complications secondary to neuraxial catherisation in labour has been approximated.

Coagulative safety of epidural catheters after major upper gastrointestinal surgery: advanced and routine coagulation analysis in 38 patients

BACKGROUND

The risk of spinal haematoma in patients receiving epidural catheters is estimated using routine coagulation tests, but guidelines are inconsistent in their recommendations on what to do when results indicate slight hypocoagulation. Postoperative patients are prone to thrombosis, and thromboelastometry has previously shown hypercoagulation in this setting. We aimed to better understand perioperative haemostasis by comparing results from routine and advanced tests, hypothesizing that patients undergoing major upper gastrointestinal surgery would be deficient in vitamin K-dependent coagulation factors because of malnutrition, or hypocoagulative because of accumulation of low molecular weight heparin (LMWH).

METHODS

Thirty-eight patients receiving epidural analgesia for major upper gastrointestinal surgery were included. We took blood at the time of preoperative epidural catheterization and at catheter withdrawal. Prothrombin time-international normalized ratio (PT-INR), activated partial thromboplastin time (aPTT) and platelet count (Plc) were analysed, and also albumin, proteins induced by vitamin K absence (PIVKA-II), rotational thromboelastometry (ROTEM®), multiple electrode aggregometry (Multiplate®) and activities of factors II, VII, IX, X, XI, XII and XIII.

RESULTS

Postoperative coagulation was characterized by thrombocytosis and hyperfibrinogenaemia. Mean PT-INR increased significantly from 1.0 ± 0.1 to 1.2 ± 0.2 and mean aPTT increased significantly from 27 ± 3 to 30 ± 4 s. Activity of vitamin K-dependent factors did not decrease significantly: FIX and FX activity increased. FXII and FXIII decreased significantly. Mean Plc increased from 213 ± 153 × 10⁶/L while all mean ROTEM-MCFs (maximal clot firmnesses) especially FIBTEM-MCF increased significantly to above the reference interval. All mean ROTEM® clotting times were within their reference intervals both before and after surgery. ROTEM® (HEPTEM minus INTEM) results were spread around 0. There were significant correlations between routine tests and the expected coagulation factors, but not any of the viscoelastic parameters or PIVKA-II. Multiplate® area under curve and EXTEM-MCF correlated significantly to Plc as did EXTEM-MCF to fibrinogen, FIX, FX and FXIII; and FIBTEM-MCF to Plc, FII, FXI and FXIII.

CONCLUSIONS

The increase in PT-INR may be caused by decreased postoperative FVII while the elevated aPTT may be caused by low FXII. The mild postoperative hypocoagulation indicated by routine tests is not consistent with thromboelastometry. The relevance of ROTEM® and Multiplate® in the context of moderately increased routine tests remains unclear. Trial registration number is not applicable since this is not a clinical trial.

The Relationship Between Patients' Anthropometric Characteristics and Depth of Spinal Needle Insertion

Background

Many surgeries are performed under spinal anesthesia. Inexperienced practitioners may find it difficult to obtain subarachnoid access.

Objectives

This study aimed to examine the relationship between patients’ anthropometric characteristics and depth of spinal needle insertion to the subarachnoid cavity.

Patients and Methods

385 patients with ASA class I – II, aged 18 - 65 years and undergoing elective surgery of the lower abdomen and extremities under spinal anesthesia, were selected for this cross-sectional study. The patients’ demographic characteristics, body mass index (BMI), and anthropometric characteristics (height, weight, waist circumference, and arm circumference) were recorded. Linear regression and t-student tests were used to study the relationship between anthropometric characteristics and BMI, and depth of needle insertion.

Results

Of the 385 patients studied, 88 were female and 297 were male. There was a strong correlation between the depth of needle insertion and BMI (24.9 ± 3.9), and between depth and weight/height ratio (r = 0.95 and r = 0.92, respectively). There was no significant correlation between depth of needle insertion and weight, height, gender, or arm circumference, when considered separately. The statistical predicting models showed that the following relationship was observed between the needle depth and the weight/height ratio: A: needle depth = 0.69 + (10.1 × weight/height); B: needle depth = 0.56 + (0.18 × BMI).

Conclusions

The results of this study show that there is a strong relationship between depth of needle insertion and BMI, and between depth and the weight/height ratio; appropriate depths can be determined according to the equations obtained.

Continuous lumbar/thoracic epidural analgesia in low-weight paediatric surgical patients: practical aspects and pitfalls

PURPOSE

Continuous epidural anaesthesia attenuates perioperative stress and avoids the need for systemic opioids. In addition, it may prevent the need for postoperative mechanical ventilation. The aim of the study was to prospectively follow the perioperative course of young infants treated with continuous thoracic/lumbar epidural anaesthesia for major surgery.

METHODS

Data were collected prospectively from 44 epidural anaesthetics in 40 infants (18 premature or former premature) weighing 1,400-4,300 g who underwent major abdominal surgery (33 cases), thoracic surgery (5), or both (1), or ano-rectal surgery (5) at our centre.

RESULTS

Epidural placement was achieved easily in all cases, with high quality analgesia for 24-96 h. Tracheal extubation was delayed after 4 anaesthetics due to muscle relaxant overdose (n = 1), surgeon's request (n = 2), and systemic opioid administration before epidural anaesthesia was considered (n = 1). Intraoperative complications included haemodynamic instability (n = 1) and vascular catheter placement (n = 5). Postoperative complications included meningitis (n = 1), insertion site erythema (n = 7), apnoea (n = 6; 4 premature and 2 full-term infants) and tracheal re-intubation (n = 6).

CONCLUSIONS

Continuous epidural analgesia is effective in low-weight infants undergoing major surgery. The trachea may be extubated immediately after surgery. Attention should be paid to the unique anatomical, physiological, and pharmacological aspects. The patients should be monitored carefully for pain, respiratory failure, and meningitis (an extremely rare complication).

Epidural anaesthesia and analgesia for surgery: still going strong?

PURPOSE OF REVIEW

The discussion on the value of epidural anaesthesia and analgesia for surgery is fuelled by current controversies regarding effects on postoperative morbidity and mortality, potential benefits for outcome and the fear of rare, but catastrophic neurological complications. This review of the most recent publications on the topic since April 2002 illustrates some of the aspects contributing to the ongoing discussion.

RECENT FINDINGS

In contradiction to previous meta-analyses, recent trials could not demonstrate significant improvements of overall morbidity or mortality by epidural anaesthesia and analgesia. However, the technique was shown again to provide superior analgesia and a reduction of perioperative stress response and respiratory complications. Analysis of the current literature strongly supports that epidural anaesthesia and analgesia remains a safe practice with a low rate of severe complications, in particular in paediatric surgery. Several developments in equipment, techniques and especially drugs have been reported, resulting in improved balanced anaesthesia and analgesia and contributing to the safety of this technique.

SUMMARY

In an era of evidence-based medicine, further meta-analyses and well-planned large randomized trials have to address the controversial issues of epidural anaesthesia and analgesia and postoperative outcome. In the context of a more holistic 'rehabilitative' management of the perioperative period, this technique might well represent a key factor to improve outcome, reduce hospital stay and thereby healthcare costs. Recent innovations and developments in techniques and drugs as well as established guidelines should further minimize potential errors and harmful complications.

Case report: Cerebral vein thrombosis after subarachnoid analgesia for labour

PURPOSE

We report a case of sagittal sinus thrombosis occurring after spinal analgesia for labour to highlight the difficulty of such diagnosis in the presence of postpartum atypical headache following regional anesthesia/analgesia.

CLINICAL FEATURES

A previously healthy 21-yr-old, primiparous, preeclamptic parturient was admitted to the hospital at 37 weeks gestation for uterine contractions. Before pregnancy she was taking no medication other than oral contraceptives and was a non-smoker. Spinal analgesia was established on the first attempt at 8 cm of cervical dilation, in the setting of rapid progression of labour. Following an uneventful delivery, on the third day postpartum, the patient experienced gradual onset of an atypical headache with unclear postural character, followed by focal neurological signs five days later. Emergency neuroimaging revealed direct evidence of thrombosis in the posterior sagittal venous sinus. Anticoagulation was initiated with iv heparin (500 UI x kg(-1) x day(-1)). The patient's headache decreased progressively and full motor recovery was noted by day 14 postpartum. After 24 days, the patient was discharged without any neurological disability. Common inherited thrombophilic dispositions were absent, with the exception of a decrease in protein S level.

CONCLUSION

Central venous thrombosis, while rare, is a recognized cause of puerperium stroke. The present case highlights the importance of considering the diagnosis in the presence of postpartum atypical headache following spinal anesthesia/analgesia. Early intervention with systemic heparinization is critical when the diagnosis is confirmed.

Intracranial subdural hematoma after spinal anesthesia

Intracranial subdural hematoma is an exceptionally rare but life-threatening complication of spinal anesthesia. We report a case of intracranial subdural hematoma following spinal anesthesia for cesarean section in a 27-year-old woman. She developed a diffuse headache after surgery with a blood pressure of 220/140 mm Hg which was followed by generalized seizure activity. Her blood pressure remained high after medication with diazepam, nifedipine and magnesium sulfate. She remained unconscious with a Glasgow coma scale of 5. The cranial tomography revealed a subdural hematoma with diffuse cerebral edema and cerebral tentorial herniation. When a patient complains of postdural puncture headache and then has seizure activity, one should consider alternative diagnoses, including that of a subdural hematoma, and carry out a careful examination, including magnetic resonance imaging or computerized tomography scan.