The risk of vertebral canal complications in 2837 cardiac surgery patients with thoracic epidurals

Infectious complications following regional anesthesia: a narrative review and contemporary estimates of risk

INTRODUCTION

Infectious complications following regional anesthesia (RA) while rare, can be devastating. The objective of this review was to estimate the risk of infectious complications following central neuraxial blocks (CNB) such as epidural anesthesia (EA), spinal anesthesia (SA) and combined spinal epidural (CSE), and peripheral nerve blocks (PNB).

MATERIALS AND METHODS

A literature search was conducted in PubMed, Embase and Cochrane databases to identify reference studies reporting infectious complications in the context of RA subtypes. Both prospective and retrospective studies providing incidence of infectious complications were included for review to provide pooled estimates (with 95% CI). Additionally, we explored incidences specifically associated with spinal anesthesia, incidences of central nervous system (CNS) infections and, the incidences of overall and CNS infections following CNB in obstetric population.

RESULTS

The pooled estimate of overall infectious complications following all CNB was 9/100 000 (95% CI: 5, 13/100 000). CNS infections following all CNB was estimated to be 2/100 000 (95% CI: 1, 3/100 000) and even rarer following SA (1/100 000 (95% CI: 1, 2/100 000)). Obstetric population had a lower rate of overall (1/100 000 (95% CI: 1, 3/100 000)) and CNS infections (4 per million (95% CI: 0.3, 1/100 000)) following all CNB. For PNB catheters, the reported rate of infectious complications was 1.8% (95% CI: 1.2, 2.5/100).

DISCUSSION

Our review suggests that the risk of overall infectious complications following neuraxial anesthesia is very rare and the rate of CNS infections is even rarer. The infectious complications following PNB catheters seems significantly higher compared with CNB. Standardizing nomenclature and better reporting methodologies are needed for the better estimation of the infectious complications.

The Impact of Anesthetic Regimen on Outcomes in Adult Cardiac Surgery: A Narrative Review

Despite improvements in surgical techniques and perioperative care, cardiac surgery still is burdened by relatively high mortality and frequent major postoperative complications, including myocardial dysfunction, pulmonary complications, neurologic injury, and acute kidney injury. Although the surgeon's skills and volume and patient- and procedure-related risk factors play a major role in the success of cardiac surgery, there is growing evidence that also optimizing perioperative care may improve outcomes significantly. The present review focuses on the aspects of perioperative care that are strictly related to the anesthesia regimen, with special reference to volatile anesthetics and neuraxial anesthesia, whose effect on outcome in adult cardiac surgery has been investigated extensively.

Nationwide incidence of serious complications of epidural analgesia in the United States

BACKGROUND

This study aimed to describe the incidence and risk factors of in-hospital spinal hematoma and abscess associated with epidural analgesia in adult obstetric and non-obstetric populations in the United States.

METHODS

The Nationwide Inpatient Sample was analyzed to identify patients receiving epidural analgesia from 1998 to 2010. Primary outcomes were incidence of spinal hematoma and epidural abscess. Use of decompressive laminectomy was also investigated. Regression analyses were conducted to assess predictors of epidural analgesia complications. Differences in mortality and disposition of patients at discharge were compared in patients with and without neuraxial complications. Obstetric and non-obstetric patients were studied separately.

RESULTS

A total of 3,703,755 epidural analgesia procedures (2,320,950 obstetric and 1,382,805 non-obstetric) were identified. In obstetric patients, the incidence of spinal hematoma was 0.6 per 100,000 epidural catheterizations (95% CI, 0.3 to 1.0 × 10(-5) ). The incidence of epidural abscess was zero. In non-obstetric patients, the incidence of spinal hematoma and epidural abscess were, respectively, 18.5 per 100,000 (95% CI, 16.3 to 20.9 × 10(-5) ) and 7.2 per 100,000 (95% CI, 5.8 to 8.7 × 10(-5) ) catheterizations. Predictors of spinal hematoma included type of surgical procedure (higher in vascular surgery), teaching status of hospital, and comorbidity score. Patients with spinal complications had higher in-hospital mortality (12.2% vs. 1.1%, P < 0.0001) and were significantly less likely to be discharged to home.

CONCLUSIONS

This large nationwide data analysis reveals that the incidence of epidural analgesia-related complications is very low in obstetric population epidural analgesia and much higher in patients having vascular surgery.

High Thoracic Epidural in Cardiac Anesthesia

High thoracic epidural analgesia (HTEA) offers a distinctive opportunity to enhance postoperative recovery for the thoracic surgery patient. In the modern hospital setting with day of admission surgery, the logistics of insertion of the epidural catheter has become increasingly difficult. The greatest limitation to its use might be the believed increased risk of epidural hematoma associated with anticoagulation during cardiopulmonary bypass. The aim of this review is to give an overview of complications and effect on outcomes with focus on cardiac performance and postoperative glycemic control and kidney function. Patients with epidurals may have improved postoperative pulmonary function and shorter ventilation time, while impact on length of stay in the intensive care unit and hospital is not as evident. HTEA is effective in pain management, attenuates perioperative stress and seems to improve postoperative blood glucose control. Whether HTEA improves recovery and facilitates fast-track is still to be confirmed. With regard to serious postoperative complications, there is evidence of reduction in supraventricular arrhythmias and lower frequency of postoperative acute kidney injury and dialysis. There are some indications of lower short term mortality and frequency of postoperative myocardial infarctions, but only as a combined outcome. The present short-term mortality of 1% to 2% should be compared with the most pessimistic frequency of epidural hematoma being 1 in 4600 patients.