Haematoma, abscess or meningitis after neuraxial anaesthesia in the USA and the Netherlands: A closed claims analysis.

BACKGROUND: Severe complications after neuraxial anaesthesia are rare but potentially devastating. OBJECTIVE: We aimed to identify characteristics and preventable causes of haematoma, abscess or meningitis after neuraxial anaesthesia. DESIGN: Observational study, closed claims analysis. SETTING: Closed anaesthesia malpractice claims from the USA and the Netherlands were examined from 2007 until 2017. PATIENTS: Claims of patients with haematoma (n = 41), abscess (n = 18) or meningitis (n = 14) associated with neuraxial anaesthesia for labour, acute and chronic pain that initiated and closed between 2007 and 2017 were included. There were no exclusions. MAIN OUTCOME MEASURES: We analysed potential preventable causes in patient-related, neuraxial procedure-related, treatment-related and legal characteristics of these complications. RESULTS: Patients experiencing spinal haematoma were predominantly above 60 years of age and using antihaemostatic medication, whereas patients with abscess or meningitis were middle-aged, relatively healthy and more often involved in emergency interventions. Potential preventable causes of unfavourable sequelae constituted errors in timing/prescription of antihaemostatic medication (10 claims, 14%), unsterile procedures (n = 10, 14%) and delay in diagnosis/treatment of the complication (n = 18, 25%). The number of claims resulting in payment was similar between countries (USA n = 15, 38% vs. the Netherlands n = 17, 52%; P = 0.25). The median indemnity payment, which the patient received varied widely between the USA (&OV0556;285 488, n = 14) and the Netherlands (&OV0556;31 031, n = 17) (P = 0.004). However, the considerable differences in legal systems and administration of expenses between countries may make meaningful comparison of indemnity payments inappropriate. CONCLUSIONS: Claims of spinal haematoma were often related to errors in antihaemostatic medication and delay in diagnosis and/or treatment. Spinal abscess claims were related to emergency interventions and lack of sterility. We wish to highlight these potential preventable causes, both when performing the neuraxial procedure and during postprocedural care of patients.

Trends in practice and safety measures of epidural analgesia: Report of a national survey.

BACKGROUND: The clinical use of epidural analgesia has changed over past decades. Minimally invasive surgery and emergence of alternative analgesic techniques have led to an overall decline in its use. In addition, there is increasing awareness of the patient-specific risks for complications such as spinal haematoma and abscess. Local guidelines for management of severe neurological complications during or after epidural analgesia, ie, "epidural alert systems", have been introduced in hospitals to coordinate and potentially streamline early diagnosis and treatment. How widely such protocols have been implemented in daily practice is unknown. METHODS: We conducted a survey to analyse trends in practice, key indications, safety measures, safety reporting, and management of complications of epidural analgesia in the Netherlands. Data were gathered using a web-based questionnaire and analysed using descriptive statistics. RESULTS: Questionnaires from 85 of all 94 Dutch hospitals performing epidural analgesia were collected and analysed, a 90% response rate. Fifty-five percent reported a trend towards decreased use of perioperative epidural analgesia, while 68% reported increasing use of epidural analgesia for labour. Reported key indications for epidural analgesia were thoracotomy, upper abdominal laparotomy, and abdominal cancer debulking. An epidural alert system for neurological complications of epidural analgesia was available in 45% of hospitals. CONCLUSIONS: This national audit concerning use and safety of epidural analgesia demonstrates that a minority of Dutch hospitals have procedures to manage suspected neurological complications of epidural analgesia, whereas in the remaining hospitals responsibilities and timelines for management of epidural emergencies are determined on an ad hoc basis.

Safety and efficacy of epidural analgesia.

PURPOSE OF REVIEW: Epidural analgesia remains a widely used analgesic technique. This article aims to assess the safety of epidural analgesia by balancing efficacy and complications, of epidural analgesia for acute, labor and chronic pain. RECENT FINDINGS: Main indications for epidural analgesia include major open abdominal surgery, thoracotomy and labor analgesia. Past and current literature show that epidural analgesia leads to statistically significant, but possibly clinically less meaningful, reductions in pain scores compared with intravenous analgesia. The debate continues whether epidural analgesia leads to decreased complications and improved outcome. Noninferiority of alternative regional analgesic approaches, that is continuous-wound-infiltration, peripheral nerve blocks or surgical site infiltration, appears to be present and is promising for the future. Serious adverse events after epidural analgesia seem to occur more often than was previously thought and clinicians must realize that incidence rates differ in specific perioperative patient populations. SUMMARY: Epidural analgesia for obstetric analgesic purposes is considered to be well tolerated in young, healthy women, since efficacy has been proven and complications leading to permanent neurological damage seldomly occur. Safety of epidural analgesia for perioperative and chronic pain treatment is more difficult to balance; careful selection of appropriate patients cannot be over-emphasized.

Differences in the Incidence of Hypotension and Hypertension between Sexes during Non-Cardiac Surgery: A Systematic Review and Meta-Analysis.

Background: Major determinants of blood pressure (BP) include sex and age. In youth, females have lower BP than males, yet in advanced age, more pronounced BP increases result in higher average BPs in females over 65. This hypothesis-generating study explored whether age-related BP divergence impacts the incidence of sex-specific intraoperative hypotension (IOH) or hypertension. Methods: We systematically searched PubMed and Embase databases for studies reporting intraoperative BP in males and females in non-cardiac surgery. We analyzed between-sex differences in the incidence of IOH and intraoperative hypertension (primary endpoint). Results: Among 793 identified studies, 14 were included in this meta-analysis, comprising 1,110,636 patients (56% female). While sex was not associated with IOH overall (females: OR 1.10, 95%CI [0.98-1.23], I2 = 99%), a subset of studies with an average age ≥65 years showed increased exposure to IOH in females (OR 1.17, 95%CI [1.01-1.35], I2 = 94%). One study reported sex-specific differences in intraoperative hypertension, with a higher incidence in females (31% vs. 28%). Conclusions: While sex-specific reporting on intraoperative BP was limited, IOH did not differ between sexes. However, an exploratory subgroup analysis offers the hypothesis that females of advanced age may face an increased risk of IOH, warranting further investigation.

The Options for Neuraxial Drug Administration.

Neuraxial drug administration, i.e., the injection of drugs into the epidural or intrathecal space to produce anesthesia or analgesia, is a technique developed more than 120 years ago. Today, it still is widely used in daily practice in anesthesiology and in acute and chronic pain therapy. A multitude of different drugs have been introduced for neuraxial injection, only a part of which have obtained official approval for that indication. A broad understanding of the pharmacology of those agents is essential to the clinician to utilize them in a safe and efficient manner. In the present narrative review, we summarize current knowledge on neuraxial anatomy relevant to clinical practice, including pediatric anatomy. Then, we delineate the general pharmacology of neuraxial drug administration, with particular attention to specific aspects of epidural and intrathecal pharmacokinetics and pharmacodynamics. Furthermore, we describe the most common clinical indications for neuraxial drug administration, including the perioperative setting, obstetrics, and chronic pain. Then, we discuss possible neurotoxic effects of neuraxial drugs, and moreover, we detail the specific properties of the most commonly used neuraxial drugs that are relevant to clinicians who employ epidural or intrathecal drug administration, in order to ensure adequate treatment and patient safety in these techniques. Finally, we give a brief overview on new developments in neuraxial drug therapy.

Perioperative approach of allergic patients.

Perioperative allergic reactions are rare, yet important complications of anesthesia. Severe, generalized allergic reactions called anaphylaxis are estimated to have a mortality of 3.5-4.8%. Adequate recognition and handling of a severe perioperative anaphylactic reaction result in better outcomes, including less hypoxic-ischemic encephalopathy and death. The diagnosis of a perioperative allergic reaction can be difficult as the list of possible culprits of a perioperative allergic reaction is extensive. Making an informed guess on the causative agent and avoiding this agent in future anesthesia procedures is undesirable and unsafe. Therefore, to ensure future patient safety, a thorough investigation following a perioperative allergic reaction is mandatory. A collaborate approach by allergists and anesthesiologists is advised. In this article, we discuss the basic approach of the allergic patient and of patients with a suspected allergy to perioperatively administered medication.