Severe complications associated with epidural and spinal anaesthesias in Finland 1987-1993. A study based on patient insurance claims [see comment].

BACKGROUND: The Patient Injury Act has been in effect in Finland since 1 May 1987. This legislation is a no-fault compensation scheme and implies that if a patient during the course of medical treatment suffers any injury as a result of that treatment he or she may file a claim to the Patient Insurance Association (PIA). From 1 May 1987 to 31 December 1993, 23,500 claims for compensation were made. METHODS: All claims made to PIA involving spinal and epidural anaesthesias during the above period were collected and reviewed and a data base was prepared. The total number of anaesthetics given during this period was estimated by sending questionnaires to every hospital in the country. RESULTS: Eighty-six claims were associated with spinal and/or epidural anaesthesia. Respectively, the total the number of spinal and epidural anaesthesias administered was 550,000 and 170,000. There were 25 serious complications associated with spinal anaesthesia: cardiac arrests (2), paraplegia (5), permanent cauda equina syndrome (1), peroneal nerve paresis (6), neurological deficits (7), and bacterial infections (4). The 9 serious complications which were associated with epidural anaesthesia were: paraparesis (1), permanent cauda equina syndrome (1), peroneal nerve paresis (1), neurological deficit (1), bacterial infections (2), acute toxic reactions related to the anaesthetic solution (2), and overdose of epidural opioid (1). CONCLUSIONS: According to this material the incidence of serious complications was 0.45:10,000 following spinal and 0.52:10,000 following epidural anaesthesia. Atraumatic technique, careful patient selection and early diagnosis and treatment of complications are essential in avoiding permanent injury.

Seizures associated with propofol anesthesia.

Propofol is a new, fast-acting intravenous (i.v.) anesthetic. Involuntary movements or epileptic seizures have occurred during or after propofol-induced anesthesia in approximately 50 reported cases; a third of the patients have had epilepsy. We report 5 patients with seizures in association with propofol anesthesia. A female epileptic patient developed severe status epilepticus; the other patients with short-lasting seizures had no previous epilepsy. Although propofol has been used in treatment of patients of status epilepticus, the risk of precipitation of epileptic seizures warrants consideration especially when planning anesthesia for epileptic patients.

Catecholamines in shock.

The role of endogenous catecholamines in various clinical shock and stress states is reviewed; the effects, especially on the peripheral circulation, of catecholamine secretion are the same independent of the cause. Risks of using sympathomimetic agents in the treatment of shock are evaluated. A prolonged noradrenaline activity is to be expected in surgical stress states, e.g. multiple injuries, fat embolism syndrome, burns and infections; therapeutic approaches to minimize the sympathoadrenal activity are outlined.

[Serum enzymes in seriously injured patients]. / Serumenzyme bei Schwerverletzten

In 45 patients with multiple injuries due to trauma, admitted consecutively to our clinic, the following enzyme activities were studied, beginning at the onset of treatment: SDH, GPT, GLDH, and acid phosphatase. The mean levels of SDH rose in all patients between 2 and 24 h after trauma. The mean values of GPT were above normal between 2 and 48 h after trauma; this rise was more pronounced and statistically significant in those patients who eventually died of trauma than in the less severely injured ones. Twenty-four hours after trauma, the levels of GLDH were 16 times higher in the first group of patients than in the less severely injured group. These results lead us to the conclusion that through serum level measurements of these enzymes particularly of GPT it is possible to evaluate the degree of tissue damage and the general state of this group of patients.

Biochemical quantification of blunt injuries.

During eight post-traumatic days, the blood loss and severity of trauma were correlated with the blood levels of lactate, creatinine and catecholamines in 45 patients with multiple blunt injuries. During two days these biochemical indicators correlated with the extent of thoracoabdominal, pelvic and cerebral injuries. In the critically injured patients all three parameters were elevated throughout the observation period. No correlations were observed between plasma catecholamines and lower limb injuries, which seems to make the importance of catecholamines for predicting the onset of fat embolism syndrome less useful.

Plasma catecholamines in severely injured patients: a prospective study on 45 patients with multiple injuries.

Plasma catecholamine levels were studied in 45 severely injured patients for 8 days after the trauma. Sixteen of the patients were classified as critically injured and 29 as seriously injured. The total plasma catecholamine values of the whole group immediately after the injury were almost twice as high as the eighth day reference values and remained significantly higher than these values for 6 hours after the trauma. On admission both the plasma adrenaline and noradrenaline levels were elevated. The plasma adrenaline levels on admission correlated with the blood volume replacement which was required within the first 6 hours. The plasma noradrenaline levels in the critically injured group were significantly higher throughout the observation period than in the seriously injured group. A corresponding difference was observed in the plasma adrenaline concentrations only during the first 12 hours. The results showed that strong stimulation of the sympathetic nervous system occurs in severely injured patients. Factors stimulating the sympathetic nervous system apparently included hypovolaemia, tissue hypoxia, acidosis and the pain produced by the trauma and therapeutic measures.

Fat embolism in severely injured patients.

Forty-five patients with severe blunt injuries were examined during eight posttraumatic days. At random, 14 patients were given three doses of methylprednisolone intravenously; 10 mg/kg at 8-hour intervals. Fat embolism syndrome was diagnosed in 13/45 patients, only one of whom had received corticosteroid (p = 0.03). Shock, acidosis and elevated plasma catecholamines showed no correlation with the occurrence of fat embolism syndrome. Platelet counts immediately after trauma were significantly lower in the fat embolism patients than in the other trauma patients, indicative of early platelet aggregation. Prophylactically administered methylprednisolone in pharmacological doses appeared to inhibit the emergence of fat embolism syndrome.

The effect of drug therapy without volume replacement in experimental traumatic shock. Part I. Phenoxybenzamine and dopamine.

The effect of phenoxybenzamine and dopamine on the respiratory and metabolic changes in experimental traumatic shock was examined in 45 rabbits. Phenoxybenzamine caused a more effective release of the peripheral vasoconstriction than dopamine. The effect of these drugs without similar restoration of blood volume was unfavourable. This should be borne in mind when the use of these drugs is meditated in clinical work.

The effect of drug therapy without volume restoration in experimental traumatic shock. Part II. Pethidine.

Different opinions seem to exist as to the use of analgesies in the treatment of trauma patients. For this reason we investigated experimentally the effect of pethidine in traumatic shock. Pethidine was administrated to eight of sixteen anaesthetized rabbits with lower limb injuries. The effect of pethidine was unfavourable. This was due to the effect of the drug on circulation and not on respiration.

The effect of drug therapy without volume restoration in experimental traumatic shock. Part III. Glucocorticoid.

The effects of methylprednisolone in connexion with a standardized trauma was studied on 30 rabbits. The treatment with glucocorticoid accentuated the hemodilution due to the trauma. Intensified lactacidosis was also demonstrated.