Complication regional block which include spinal and epidural
- 1. COMPLICATIONS OF REGIONAL BLOCK GROUP 5 Aug 15, 2024 Adds Ababa university Anesthesia student seminar
- 2. Outlines • Introduction • Common complications of regional anesthesia with their risk assesment and management Ø Spinal , Epidural , caudal/ neuraxial anesthesia Ø Upper extremity block and Lower extremity block ØOther common blocks • References 2
- 3. Introduction • In the realm of anesthesia, regional blocks play a crucial role in providing targeted pain relief and facilitating surgical procedures while minimizing systemic effects. • This presentation delves into the complications associated with various regional blocks, including neuraxial anesthesia (spinal and epidural), upper extremity blocks (such as interscalene and supraclavicular blocks), lower extremity blocks (including femoral and sciatic nerve blocks), and other specialized techniques. • Each type of block presents unique risks and potential complications, ranging from local anesthetic systemic toxicity to nerve injury and infection. Effective risk assessment and management strategies are essential to mitigate these complications and ensure patient safety. 3
- 4. Spinal , Epidural , caudal/ neuraxial anesthesia 4
- 5. Complications of neuraxial block 1. Post dural puncture headache • Headache is one of the most common complications of both intentional and unintentional dural puncture. • It is due to leakage of cerebrospinal fluid (CSF) through the dural defect at a rate faster than that of CSF production. • During upright position, gravity causes traction on highly innervated meninges and pain sensitive intracranial vessels. • This cause pain to the frontal, occipital and neck and shoulder region via trigeminal, glossopharyngeal, vagand upper cranial nerves 5
- 6. Risk assesment Risk factors of PDPH are ; v Larger Needle size (22-24 Gauge) vMultiple puncture attempt vyoung age vfemale sex vprevious spinal surgery vpregnancy vprior history of PDPH... 6
- 7. Strategies to Minimize PDPH Risks: 1. Needle Selection: * Use smaller Needles (25-27 Gauge) * Consider Pencil-Point Beveled Needles: These needles have a smaller tip diameter, potentially reducing dural damage. 2. Techniques: * Single Puncture Attempt * Modified Loss of Resistance (LOR) Technique: This technique helps to identify the epidural space with less pressure, potentially reducing dural injury. * Minimize CSF Leakage: If CSF leakage is encountered, minimize its leakage by carefully withdrawing the needle. 7
- 8. Management q Management could be conservative or invasive. The conservative measures include: • bed rest, • hydration, • analgesics, • caffeine. These measures will decrease downward traction, increase CSF production, constrict the intracranial vessels and provide the symptomatic relief
- 9. Con.. • The invasive treatment is epidural blood patch • which is considered to be most effective treatment in complete resolution of most of the symptoms. • Aseptically withdrawn autologous blood is injected in the same space or one space below • until the patient experiences lumber discomfort or until 20 ml has entered in epidural space.
- 10. 2. High Block/Total Spinal Block when there is unintentional intrathecal administration of high doses of local anaesthetics during epidural or caudal anaesthesia. • onset is usually rapid. • severe hypotension • Bradycardia • Nausea and Vomiting • respiratory insufficiency. • If unrecognized or not managed properly, high levels of block can produce respiratory compromise and cardiac arrest 10
- 11. Risk assesment Risk factors Cardiovascular Disease Respiratory Conditions Age: Medications: Previous Anesthesia: It can be avoided by; • taking history and physical examination • Careful aspiration • use of test dose and • incremental drug dosing 11
- 12. Management • Put in trandlenburg position so as to increase venous return, administer fluid along with inotropic support to raise blood pressure, • Tracheal intubation to support ventilation. • Monitoring: Closely monitor vital signs (heart rate, blood pressure, oxygen saturation), respiratory rate, and level of consciousness. • Emergency Equipment: Have emergency equipment readily available, including oxygen, ventilators, vasopressors, and medications to treat bradycardia and seizures. • Pre-medication • Careful Dose Adjustments: • Fluid Management: • Post-Procedure Monitoring: 12
- 13. 3. Systemic Toxicity • Signs and symptoms range from tinnitus and metallic taste to seizures and cardiac arrest. • Neurological Symptoms: Seizures, altered mental status, confusion, or loss of consciousness. • Cardiovascular Symptoms:Bradycardia, hypotension, arrhythmias, or cardiac arrest. Important safety steps to prevent local anesthetic toxicity include ; • Incremental injection, • Limiting the total dose of local anesthetic, and using a test dose that contains a marker for intravascular injection 13
- 14. Risk assesment • Risk Factors: * High-Dose Local Anesthetics: * Rapid Injection: * Certain Anesthetic Agents: * Age: * Body Mass Index: * Liver or Kidney Dysfunction, Cardiac Conditions: Spinal anesthesia is associated with a higher risk of systemic toxicity compared to epidural anesthesia due to the direct proximity of the spinal canal to the bloodstream. * Multiple Puncture Attempts: * Accidental Intrathecal Injection: 14
- 15. Wecanavoiditby; • Taking proper history and physical examination: • Thorough Anatomical Knowledge: • Aspirate Before Injection: • Use a Test Dose: • Slow Injection Rate: • Close Monitoring: Carefully monitor vital signs (heart rate, blood pressure, oxygen saturation), neurological function, and any signs of toxicity throughout the procedure. 15
- 16. Management qImmediate Actions • Stop the Procedure: Discontinue the neuraxial block immediately. • Call for Help: Alert the anesthesia team and ensure emergency protocols are activated. q Airway Management • Ensure Patency: • Supplemental Oxygen qSeizure Management • Benzodiazepines:Administer lorazepam or midazolam intravenously for seizure control. • Positioning:Place the patient in a lateral position to prevent aspiration. 16
- 17. qLipid Emulsion Therapy • Dosage: Administer a bolus of 20% lipid emulsion (e.g., 1.5 mL/kg over 1 minute), followed by a continuous infusion (0.25 mL/kg/min). Adjust based on clinical response qCardiovascular Suppor • Monitor Vital Signs:Continuous monitoring of heart rate, blood pressure, and oxygen saturation. • iV Fluids: Administer IV fluids to support blood pressure if hypotension occurs. 17
- 18. qMedications: • Bradycardia: Atropine may be administered if bradycardia is significant. • Hypotension: Consider vasopressors (e.g., ephedrine or phenylephrine) if fluid resuscitation is inadequate. qAdvanced Cardiac Life Support (ACLS) Protocol • If the patient progresses to cardiac arrest, initiate ACLS protocols immediately. 18
- 19. 4.INFECTION • Meningitis: Dural puncture may be a risk for infection of subarachnoid space. • the infectious source may be exogenous (e.g., contaminated equipment or medication) • endogenous (a bacterial source in the patient seeding to the needle or catheter site). • Microorganisms can also be transmitted via a break in aseptic technique, 19
- 20. Initial clinical presentation are; • fever and headache, • backache with emesis, • classical sign of meningism and lithargy. 20
- 21. Risk assesment Risk Factors: * Multiple Puncture Attempts: * Catheter Placement: * Non-Sterile Technique: * Immunocompromised Patients: * Skin Infections: * Obesity: * Environmental Factors: 21
- 22. We can avoid it by; • Assess the patient for any history of skin infections, spinal infections, or other infections and identify patients with conditions that weaken the immune system. • Physicaly examine for injection site for any signs of infection (redness, swelling, warmth, pus) and Look for any signs of illness, like fever, chills, or malaise. • Sterile Technique: Ensure strict adherence to sterile technique during the procedure. • Disposable Supplies: Use disposable needles, catheters, and other equipment to prevent cross-contamination. • Proper Skin Preparation: Cleanse the injection site thoroughly with antiseptic solution. 22
- 23. Management • Keep aseptic techniques properly • Avoid the procedure if ther is infection in that site • Give appropriate antibiotics early 23
- 24. 5. Urinary retention • Neuraxial anaesthesia blocking S2-S4 nerve root fibres decreases the urinary bladder tone and inhibits the voiding reflex. • Lower concentrations of local anaesthetic are needed for paralysis of urinary bladder than motor nerves of lower extremities. • Inappropriate management of POUR may be responsible for bladder over distension, urinary tract infection, and catheter- related complications. 24
- 25. Risk Factors: vHigh Blocks: Blocks affecting the thoracic or upper lumbar spinal segments are more likely to cause urinary retention because they affect the nerves controlling bladder function. v Age: Elderly v Pre-existing Bladder Conditions: Patients with urinary incontinence, urinary retention, or other bladder issues are more susceptible to complications. vProstatic Hyperplasia v Prolonged blocks 25
- 26. wecanavoiditby; Taking Patient History and physical examination • Urinary Problems: inquire about any history of urinary incontinence, urinary retention, prostate problems, or difficulty voiding. • Previous Anesthesia: ask about previous experiences with neuraxial blocks and any complications. • Bladder Examination: assess bladder distention by palpation. 26
- 27. Management qEncourage Voiding: qCatheterization q For patients who don't require a long-term catheter, intermittent catheterization can be used to empty the bladder at regular intervals. q Cholinergic Agents: Medications like ; bethanechol stimulate bladder contraction if appropriate and safe for the patient. • Analgesia: Ensure adequate pain control, as discomfort may inhibit the ability to void. 27
- 28. 6. Block failure Risk Factors • Incorrect Needle Placement • Anatomical Variations • Inexperienced practitioners • Obesity • Previous Surgery • positioning, • Inadequate Dosage • Drug of Choice 28
- 29. Strategies to Avoid Block Failure • Proper Technique • Thorough Assessment • Continuous education and training in neuraxial techniques for practitioners. • Use appropriate local anesthetic agents and dosages 29
- 30. Management • Evaluate the extent and level of the block to determine the cause of failure. • Communication with the Patient • Supplemental Analgesia • Re-blocking • Converting to a general anesthesia • Monitoring and Support 30
- 31. Upper Extermity Nerve Block - ü Upper extermity block can be done with either brachial plexus(interscalene, supraclavicular and infraclavicular) or terminal nerves (median, ulnar, radial, and m.cutaneous nerve) at axilla or distal parts/ wrist block. 31
- 32. Lower Extermity Nerve Block üInnervations of the leg is derived from the lumbar plexus (L1- L4) and lumbo sacral plexus formed by (L4-S5). 32
- 33. Complications of peripheralNerveblock( Upper and Lower ExtremityBlock),and Management 1. Peripheral Nerve Injury • Associated with needle trauma, inadvertent injection of the nerve, or high injection pressures. • if intraneural injuction occur the patient complains a sharp pain. The injection should be stopped immediately. Symptoms: persistent paresthesia, aching or sensory or motor deficits. 33
- 34. Management • Reassure the patient and provide information about the potential for recovery. • Monitor for changes in sensory and motor function. • Supportive care, including physical therapy and occupational therapy. • Pain management with medications (e.g., NSAIDs, neuropathic pain agents). • Surgical intervention may be necessary in cases of severe or persistent injury • Further evaluation, imaging studies, and potential treatments can be initiated by a neurologist or anesthesiologist experienced in managing nerve injuries. 34
- 35. 2.Allergic reactions Management ØClose monitoring and Provide supplemental oxygen and IV fluids as needed. Ø Emergency preparedness: If an allergic reaction is suspected, discontinuing the medication and administering appropriate medications, • If Mild Reaction: Administer antihistamines (e.g., diphenhydramine) • If Severe Reaction (Anaphylaxis): Administer epinephrine (0.3–0.5 mg IM for adults). 35
- 36. 3. Vascular Injury Management • Apply direct pressure to control bleeding. • Monitor for signs of hematoma formation or significant swelling. • If a hematoma develops, observe for resolution; drainage may be required if it Compresses surrounding structures. • Consult vascular surgery if there is significant vascular compromise or Persistent bleeding. 36
- 37. 4.Pneumothorax üAssociated with Supraclavicular blocks Management q Observe for small, asymptomatic pneumothorax; it often resolves spontaneously. q Significant Pneumothorax: - Administer supplemental oxygen to help reabsorb air. - If symptomatic or large, consider chest tube placement or needle decompression 37
- 38. 5. Horner’s syndrome Management • Reassure the patient; Horner's syndrome is usually self-limiting. • Follow-Up - Monitor for resolution over days to weeks. - If symptoms persist or worsen, consider further evaluation to rule out other causes. 6. Transient Neurological Symptoms (TNS) It is a Short-term pain or dysesthesia following a block. Risk Factors: Associated with certain types of blocks (e.g. popliteal). Management - Usually self-limiting; reassurance and symptomatic treatment. 38
- 39. 7. Hemi-diaphragmatic paralysis • The proximity of the phrenic nerve and its originating cervical roots to the brachial plexus often lends to unintended local anesthetic blockade and diaphragmatic dysfunction. • The incidence is 100% after inter-scalene block Management • Vigilant monitoring • Oxygen supplementation: • Airway management: • Applying continuous positive airway pressure (CPAP) or administering assisted ventilation using a bag-valve-mask or an endotracheal tube. 39
- 40. 8. Local Anesthetic Systemic Toxicity (LAST) Management • Stop the injection immediately. • Ensure airway management and provide supplemental oxygen • Immediate treatment: provide adequate ventilation, oxygenation, and circulation (CPR) • Administer IV lipid emulsion therapy (e.g., 20% lipid emulsion, bolus of 1.5 mL/kg over 1 minute, followed by a continuous infusion). • Supportive care, including monitoring cardiac function and vital signs. 40
- 41. Here are some complications and management for common blocks like TAP block, Paravertabral block and Rectus sheath block 41
- 42. TAP block • TAP block is a regional anesthetic technique that targets the nerves that supply the abdominal wall. The local anesthetic is injected into the transversus abdominis plane (TAP), a space between the internal oblique and transversus abdominis muscles. • Target Nerves * Intercostal nerves: Nerves that run between the ribs. * Thoracoabdominal nerves: Nerves that extend from the thoracic region (chest) to the abdominal wall. * Iliohypogastric nerve: A nerve that supplies the lower abdomen. * Ilioinguinal nerve: A nerve that supplies the groin and upper thigh. 42
- 43. • Bleeding: This is the most common complication, especially in patients with bleeding disorders or those taking blood thinners. Management: Applying pressure to the injection site for a few minutes can help control bleeding. If bleeding is severe, further intervention may be needed. • Nerve Injury: While uncommon, nerve injury is possible if the needle punctures a nerve during injection. Management: Most nerve injuries are temporary and resolve on their own. In rare cases, permanent nerve damage can occur, which might require physical therapy or other treatments. 43
- 44. • • Local Anesthetic Toxicity: This occurs when too much local anesthetic is injected or it's absorbed into the bloodstream too quickly. Symptoms include dizziness, nausea, confusion, slurred speech, and seizures. • Management: Treatment involves supportive care, such as oxygen, intravenous fluids, and medications to control seizures. • Hematoma: A collection of blood under the skin at the injection site. This can cause pain and swelling. Management: Usually resolves on its own. In some cases, it may need to be drained. • Infection: Infection is rare but can occur at the injection site. Management: treatment typically involves antibiotics. 44
- 45. Paravertebral block • A paravertebral block is a regional anesthesia technique where local anesthetic is injected near the nerves that exit the spinal cord through openings called intervertebral foramina. It's performed close to the vertebral column (spine). • Target Nerves: Paravertebral blocks target the intercostal nerves, which run between the ribs and supply the chest wall, as well as the thoracoabdominal nerves, which extend from the chest to the abdomen. 45
- 46. • Pneumothorax- a collapsed lung,which is a serious complication that may occur if the needle punctures the lung . Management- Treatment often involves inserting a chest tube to drain the air from the chest cavity • All the complications and management's are the same with TAP but in addition close Monitoring, controlling bleeding ,having experienced provider ,careful selection of patient and proper techniques can be listed. 46
- 47. Rectus Sheath Block The rectus sheath block involves the injection of local anesthetic into the rectus sheath, which is the fibrous compartment surrounding the rectus abdominis muscle. This technique aims to provide effective pain relief by blocking the sensory nerves that supply the skin and muscles of the anterior abdominal wall. - Target Nerves: The primary nerves targeted by the rectus sheath block include: 1. **T7 to T11 Thoracoabdominal Nerves**: These nerves provide sensory innervation to the skin and muscles of the lower thorax and upper abdomen. 2. **Subcostal Nerve (T12)**: Supplies sensation to the lower abdominal wall. 3. **Iliohypogastric and Ilioinguinal Nerves**: These nerves, which arise from L1, also contribute to sensation in the lower abdominal region. By blocking these nerves, the rectus sheath block can effectively reduce pain during and after surgical procedures in the lower abdomen, such as hernia repairs or cesarean sections. 47
- 48. Complications: • Intravascular Injection- Risk of LAST. • Hematoma- Due to vascular puncture. • Infection- At the injection site. • Nerve Injury- Rare but possible. Management: • Intravascular Injection- Similar management as TAP block for LAST. • Hematoma- Monitor and manage with pressure; surgical intervention if necessary. • Infection- Administer antibiotics as needed. • Nerve Injury- Monitor for symptoms; refer if persistent. 48
- 49. References: • Morgan and Mikhail’s clinical anesthesiology , 6th edition • Barash 8th edition • American socity of anesthesiologist website • World Federation of Societies of Anesthesiologists website 49
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