Serious complications associated with spinal and epidural anaesthesia in Finland from 2000 to 2009.

BACKGROUND: Analyses of closed claims provide insight into the characteristics of rare complications. Serious complications related to spinal and epidural blocks are relatively rare. In Finland, all malpractice cases are primarily handled by the Patient Insurance Centre (PIC) within a 'no-fault scheme'. METHODS: All claims attributed to central neuraxial blocks and settled by the PIC during the period, 2000-2009 were analysed. The number of spinal and epidural procedures performed during this time was estimated based on a questionnaire sent to all surgical hospitals in Finland in 2009, surveying the numbers and types of neuraxial blocks carried out in 2008. RESULTS: During the study period, 216 closed claims were flagged with spinal or epidural blocks. In 41 of 216 instances, the neuraxial block was apparently responsible for a serious (fatal or critical or lasting >1 year) complication. These included six fatalities and 13 epidural haematomata (two in conjunction with fondaparinux, three with excessive doses of low molecular weight heparins, six where present guidelines were not observed). Fatalities occurred in 1 : 775,000 spinals for surgery, 1 : 62,000 in epidurals for surgery or acute pain relief, 1 : 12,000 epidurals for chronic pain relief, 1 : 89,000 in combined spinal and epidural for surgery, and 1 : 144,000 epidurals for labour. The incidence of neuraxial haematoma after spinal block was 1 : 775,000, that for epidural block 1 : 26,400, and in the case of combined spinal and epidural, 1 : 17,800. Irrespective of the method of neuraxial technique, the majority of patients suffering serious complications were the elderly having comorbidities. CONCLUSIONS: In this closed claims analysis, major problems related to neuraxial blocks were rare. Epidural or a combined spinal and epidural technique resulted in more complications than did spinal procedure.

Chloroprocaine 40 mg produces shorter spinal block than articaine 40 mg in day-case knee arthroscopy patients.

BACKGROUND: Articaine and chloroprocaine have recently gained interest as short-acting spinal anaesthetics. Based on previous work comparing articaine 60 mg with chloroprocaine 40 mg, we hypothesised that articaine 40 mg and chloroprocaine 40 mg would produce similar spinal anaesthesa regarding block onset, maximal spread, and recovery. METHODS: In this randomised, double-blind study, adult patients (18-70 years, American Society of Anaesthesiologists physical status I-III, BMI < 36 kg/m(2) ) scheduled for day-case knee arthroscopy received either articaine 40 mg (20 mg/ml) (group A40, n = 16) or chloroprocaine 40 mg (20 mg/ml) (group C40, n = 18) intrathecally. Telephone interviews were performed on the first and seventh postoperative day to disclose possible side effects, e.g. transient neurological symptoms (TNS). RESULTS: The groups were comparable regarding demographic data, onset and maximal spread of spinal anaesthesia, and duration of surgery. Surgery could be performed successfully under spinal anaesthesia except once in A40 (insufficient block) and once in C40 (prolonged surgery). Complete recovery was significantly slower in A40 vs. C40 for both motor block (105 (94/120) vs. 75 (71/90) min) [P < 0.001, Mann-Whitney U-test (MW-U)] and sensory block [135 (109/176) vs. 105 min (90/124)] (P < 0.02, MW-U), respectively [data are median (25th/75th percentiles)]. One patient from A40 showed mild TNS. CONCLUSION: Both A40 and C40 provided mainly adequate spinal anaesthesia for day-case knee arthroscopy. While onset and maximal spread were comparable, the recovery from motor block was clearly faster with chloroprocaine after equivalent doses of spinal articaine and chloroprocaine.

Local infiltration analgesia with levobupivacaine compared with intrathecal morphine in total hip arthroplasty patients.

BACKGROUND: Recently, local infiltration analgesia (LIA) has been promoted for pain control after total hip arthroplasty (THA). We hypothesized that LIA would offer equal analgesic efficacy but less adverse effects, e.g., nausea and vomiting, when compared with an established regimen [intrathecal morphine (it-M)] after THA. METHODS: This randomized controlled trial comprised 60 patients undergoing THA under spinal anaesthesia. For LIA, the surgeon administered levobupivacaine, ketorolac and epinephrine at the surgical site intraoperatively. LIA patients received a LIA top-up through a wound catheter on the morning of the 1st post-operative day (POD). In group it-M, 0.1 mg morphine was given together with the spinal anaesthetic. Study parameters included pain scores, vital parameters and side effects, e.g., post-operative nausea and vomiting (PONV). Besides, levobupivacaine plasma concentrations were determined in 10 LIA patients. RESULTS: The median (25th/75th percentiles) rescue oxycodone demand differed significantly with LIA 15 (10/25) mg vs. 8.5 (1.5/15) mg with it-M (P < 0.006) during the day of surgery, but not anymore on 1st or 2nd POD. The LIA top-up had no effect. However, both analgesic regimens resulted in comparable pain scores and patient satisfaction. PONV incidence and medication did not vary significantly. LIA offered certain advantages regarding early post-operative mobilization. Maximum levobupivacaine plasma concentrations (229-580 ng/ml) remained under the toxic level. CONCLUSIONS: While LIA might enable earlier mobilization after THA, it was not associated with less nausea as compared with it-M. Less rescue oxycodone was given early after it-M, but urinary retention was more common in that group.

Chloroprocaine vs. articaine as spinal anaesthetics for day-case knee arthroscopy.

BACKGROUND: Chloroprocaine and articaine have recently gained interest as short-acting spinal anaesthetics. They have not, however, previously been compared in an ambulatory surgery setting. METHODS: In this double-blind, randomised, controlled trial, adult patients (≤65 years, ASA I-II, body mass index<36 kg/m2) underwent day-case knee arthroscopy under spinal anaesthesia with either 40 mg of plain chloroprocaine (20 mg/ml) (group C40; n=39) or 60 mg of plain articaine (40 mg/ml) (group A60; n=39). Study parameters included the onset, degree, and regression of both sensory and motor block. Standardised telephone interviews on the first and seventh post-operative day were aimed at detecting any untoward sequelae, e.g., transient neurologic symptoms (TNSs). RESULTS: The groups were comparable regarding demographic data, onset and maximal spread of spinal anaesthesia, and duration of surgery. All arthroscopies were performed successfully under spinal anaesthesia, except for one patient (C40, unforeseen delay in the start of surgery). The duration of sensory block≥dermatome L1 was significantly shorter in C40 vs. A60. Correspondingly, complete recovery was significantly faster (P<0.0001, Mann-Whitney U-test) in C40 vs. A60 for both motor [75 (60/90) vs. 135 (105/150) min] and sensory [105 (105/135) vs. 165 (135/180) min] block, respectively [data are median (25th/75th percentiles)]. No TNSs were noted. CONCLUSIONS: Both anaesthetics used provided a rapid onset of spinal anaesthesia of about 1 h and were satisfactory for day-case knee arthroscopy. Recovery, however, was significantly faster in group C40. The data add to earlier results that TNSs seem to be uncommon after spinal chloroprocaine and articaine.

Continuous spinal microcatheter (28 gauge) technique for arterial bypass surgery of the lower extremities and comparison of ropivacaine with or without morphine for postoperative analgesia.

BACKGROUND: The aim of this study was to evaluate a microcatheter technique for continuous spinal anaesthesia (CSA) and continuous spinal postoperative analgesia (CSPA) in vascular surgery. METHODS: A total of 47 patients (range 51-95 yr, ASA II-IV) undergoing peripheral bypass surgery of the lower extremities received a spinal microcatheter (28 gauge) at L3-L4 or L2-L3. For CSA, ropivacaine 7.5 mg ml(-1) was given in small increments. Central venous pressure was maintained >or=3 mm Hg. Of 47 patients, 44 received CSPA, either using ropivacaine alone 2 mg h(-1) (group R, n=22) or ropivacaine 1 mg h(-1) with morphine 8 microg h(-1) (group RM, n=22) for 24 h after surgery (randomized, double-blinded). RESULTS: Intraoperative haemodynamic control was good; during the initial 60 min only four patients received phenylephrine i.v. for hypotension. Up to 30% of the patients felt mild pain at incision but surgery [mean duration 173 min (range 66-327)] was successfully completed under CSA in 45 patients. In four instances of acute revision surgery, a new block was administered utilizing the spinal catheter in place. Postoperative pain relief was comparably adequate in both groups with no difference in rescue pain medication. Four patients (three in R, one in RM) had weak motor blockade in the first postoperative morning. CONCLUSIONS: The described CSA technique offered good haemodynamic control, ease of maintaining spinal anaesthesia, and ease of providing a new spinal block for revision. The combination of low-dose ropivacaine and morphine for CSPA did not offer any benefit compared with the higher ropivacaine dose alone.

Small dose of clonidine mixed with low-dose ropivacaine and fentanyl for epidural analgesia after total knee arthroplasty.

BACKGROUND: We studied whether a small dose of clonidine added to a ropivacaine-fentanyl mixture improves epidural analgesia without provoking side effects typically related to larger amounts of epidural clonidine. METHODS: In this randomized, double-blinded study, patients (< or =85 yr, ASA I-III) underwent total knee arthroplasty (TKA) performed under spinal anaesthesia. After the operation, patients received an epidural infusion consisting of ropivacaine 2 mg ml(-1) and fentanyl 5 microg ml(-1) either without (Group RF, n=33) or with clonidine 2 microg ml(-1) (Group RFC, n=36). The infusion rate was adjusted within the range 3-7 ml h(-1). RESULTS: Average rate of infusion was slightly smaller in Group RFC than in Group RF (mean (sd) 4.7 (0.72) vs 5.2 (0.8) ml h(-1), P=0.004). Compared with the RF group, patients in the RFC group required significantly less rescue pain medication, that is i.m. oxycodone (median (25th, 75th percentile) 0 (0, 7) vs 7 (0, 12) mg, P=0.027). Arterial pressure and heart rate were slightly lower in Group RFC throughout the study period (mean difference between the groups 5 mm Hg (P<0.002) and 3 min(-1) (P=0.12), respectively). The groups did not differ statistically with respect to nausea, motor block, and sedation. CONCLUSIONS: The small amount of clonidine added to the low-dose ropivacaine-fentanyl mixture reduced the need for opioid rescue pain medication after TKA. Clonidine slightly decreased arterial pressure and heart rate without jeopardizing haemodynamics. Otherwise, the side effect profiles were comparable in both groups.

Plasma exchange in severe postpartum HELLP syndrome.

We present a case of extremely severe postpartum HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome, associated with activation of coagulation, massive recurrent intra-abdominal bleeding requiring two laparotomies, renal failure, and central nervous system symptoms. This case underlines the complexity of pregnancy-related thrombotic microangiopathies regarding their differential diagnosis, multiple organ dysfunction, as well as management. Systemic endothelial cell injury plays a central role in the pathogenesis of thrombotic microangiopathies. Treatment of HELLP syndrome usually consists of administration of antihypertensive therapy and magnesium sulfate. No consensus exists regarding the use of plasma exchange or corticosteroids. Plasma exchange was a major part of the treatment regime in our patient. Early plasma exchange may be considered as an adjuvant therapy in severe and progressive postpartum HELLP syndrome.

Epinephrine added to a lumbar epidural infusion of a small-dose ropivacaine-fentanyl mixture after arterial bypass surgery of the lower extremities.

BACKGROUND: The addition of epinephrine (2 micro g.ml-1) to a thoracic epidural infusion of an opioid-local anesthetic mixture improves analgesia. Here, we studied whether epinephrine could improve analgesia also at lumbar level, when added to an epidural infusion of a low-dose ropivacaine-fentanyl mixture after arterial bypass surgery of the legs. METHODS: Patients in group RFE (n = 21) received a postoperative epidural infusion containing ropivacaine (1 mg.ml-1), fentanyl (2 micro g.ml-1), and epinephrine (2 micro g.ml-1). Patients in group RF (n = 25) received a similar infusion without epinephrine. The infusion speed was 1 ml.10 kg-1. h-1. The infusion was scheduled for 48 h. RESULTS: Epinephrine did not reduce the need for rescue pain medication. Visual analog scale scores (VAS) for pain at rest were low and similar in the groups. Pain intensity was stronger during leg movement [mean VAS 1.5-2.6 (range 0-9)], but it was not affected by the coadministration of epinephrine. The groups did not differ concerning frequency and severity of side-effects. Epinephrine did not reduce fentanyl plasma concentrations. Ropivacaine concentrations were slightly lower in group RFE only in the samples 6 h from the start of the infusion, but not anymore on the first and second postoperative day. CONCLUSION: In the dosage used here, epinephrine did not improve epidural lumbar analgesia. Different distances from the epidural application site to the alpha2-adrenergic receptors of the spinal cord, and differing epinephrine dose requirements may explain why epinephrine as an additive improves epidural analgesia at thoracic, but not at lumbar level.