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Year : 2009  |  Volume : 53  |  Issue : 5  |  Page : 543-553 Table of Contents     

Complications And Controversies of Regional Anaesthesia: A Review

1 Professor, Department of Anaesthesiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow-226 014, India
2 Assistant Professor Anaesthesiology, Department of Anaesthesiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow-226 014, India

Date of Web Publication3-Mar-2010

Correspondence Address:
Anil Agarwal
Department ofAnaesthesia, SGPGIMS, Lucknow 226014
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Source of Support: None, Conflict of Interest: None

PMID: 20640104

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Complications of regional anaesthesia has been recognised from very long time. Fortunately serious complica­tion are rare. Safe, effective practice of neuraxial anaesthesia requires a detailed knowledge of potential complica­tions, their incidence and risk factors associated with their occurrence. The incidence of complication were higher for spinal than for epidural anaesthesia. These complications being rare, so existing studies are mainly retrospective, providing information about incidence and their associations but not necessarily demonstrate causality.
There are many areas of controversies regarding the usage of regional anaesthesia i.e. in outpatient surgical procedures, epidural test dose, its safety in infected / febrile / immuno compromised patients, / in patients with neurological disorder and in patients receiving anti-coagulants. Recommendations proposed may be acceptable based on the judgment of the responsible anaesthesiologist. The consensus statements are designed to encourage safe and quality patient care but cannot guarantee a specific outcome.

Keywords: Regional anaesthesia, Complications, Controversies

How to cite this article:
Agarwal A, Kishore K. Complications And Controversies of Regional Anaesthesia: A Review. Indian J Anaesth 2009;53:543-53

How to cite this URL:
Agarwal A, Kishore K. Complications And Controversies of Regional Anaesthesia: A Review. Indian J Anaesth [serial online] 2009 [cited 2021 Jun 25];53:543-53. Available from: https://www.ijaweb.org/text.asp?2009/53/5/543/60332

   Complications of Regional Anaesthesia Top

Complications of regional anaesthesia have been recognised since Bier reported the first spinal anaes­thetic over 100 year ago . [1] Fortunately, serious compli­cations of neuraxial anaesthesia remain rare but can be devastating when they occur. Because of their rarities, definitive studies of complications remain problematic. Thus, most ofthe existing studies are retrospective sur­veys to provide valuable information about incidence and their possible associations.

Incidence: of neurologic central neuraxial block­ade (CNB) complications is estimated to be between 1/1000 and 1/1,000,000. [2],[3],[4],[5] Avery large survey ofre­gional anaesthesia from France showed relatively low incidence of serious complications of regional anaes­thesia [6] . The incidence of complications was higher for spinal than for epidural anaesthesia.The majority of in­stances of fatal cardiac arrest could not be directly at­tributed to spinal anaesthesia. Eighty five percent of patients with neurological deficits had complete recov­eiy within three imonths. [6] These complications maybe caused either due to mechanical injury from needle or catheter placement and/or adverse physiological re­sponses and/or drug toxicity.

   Individual complications of regional anaesthesia: Top

1.Post dural puncture headache: Bier while describingthe first spinal anaesthetic also provided the first description of post dural puncture headache (PDPH)'. PDPH is one of the most common compli­cation ofneuraxial block, with an overall incidence that maybe as high as 7 %. [7] Any breach in the dura mater, which may follow a spinal anaesthetic, an epidural "wet tap", diagnostic lumber puncture, or migration of epi­dural catheter may result in PDPH. The mechanism of PDPH is thoughtto be persistent leakage of cerebrospi­nal fluid (CS F) through the dural defect at a rate faster than that of CSF production. The transdural leak leads to decreased CSF volume and pressure. During up­right position, gravity causes traction on highly inner­vated meninges and pain sensitive intracranial vessels,which refer pain to the frontal, occipital and neck and shoulder region viatrigeminal, glossopharyngeal and vagus and upper cranial nerves respectively. [8] The di­agnosis is basically clinical, usually presents 48-72 his after the procedure, typically bilateral, fronto - occipi­tal extending up to neck and shoulders. Pain is described as dull or throbbing; usually associated with nuchal stiff­ness and backache. The hallmark of PDPH is that it is postural in nature. It often subsides during supine posi­tion and maybe associated withmalaise, photophobia, nausea, vomiting and cranial nerve palsies.

Subdural hematoma is rare but is most severe complication of PDPH [9] The risk factors of PDPH are young age, female sex, pregnancy and prior history of PDPH. [10] Use of smaller and non cutting (Whitacre) needles decreases the incidence of PDPH. [11]

As far as treatment is concerned, it could be con­servative or invasive. The conservative measures in­clude bed rest, hydration, analgesics, abdominal bind­ers and caffeine. These measures will decrease down­ward traction, increase CSF production, constrict the intracranial vessels and provide the symptomatic relief [12]

The invasive treatment is epidural blood patch, which is considered to be most effective treatment in complete resolution of most of the symptoms [13] .Aseptically withdrawn autologous blood is injected inthe same space or one space below until the patient experiences lumber discomfort or until 20 ml has entered in epidural space.

2. Backache: Backache is a frequent complaint ofneuraxial anaesthesia. Although incidence is high but neuraxial anaesthesia may not be the sole cause. [14] The frequency of backache is approximately similar after spinal or general anaesthesia [15] Localisedtraumato the intervertebral disk or excessive stretching of associ­ated ligaments after loss of lumber lordosis due to re­laxation ofparaspinal muscles are supposed to be the causative factors. The pain is usually mild and self lim­iting although it may last for several weeks. Nonsteroi­dal anti-inflammatory agents and warm or cold com­ presses are sufficient forbackache. Although backache is usually benign, it may be an indication ofmore seri­ous complications like epidural abscess, spinal he­matoma or syndrome of transient neurologic symptoms.

3. Transient Neurological symptoms: Tran­sient neurological symptoms (TNS) were first reported in 1993 by Schneider et al who described the devel­opment of severe radicular back pain after resolution of an uneventful, lidocain spinal anaesthetic. [16] There was no sensory or motor deficit and no signs ofboweb and bladder dysfunction. The symptoms resolved within one week. The aetiology of TNS is not well defined. However, up to 30% of patients with TNS report se­vere pain. [17] Zoric et al in their systemic review analysed that the use of lidocauie for spinal anaesthesia increased the risk of developing TNS. There was no evidence that this painful condition was associated with any neurologic pathology, the symptoms disappeared spontaneously by the fifth postoperative day. The risk of developing TNS after spinal anaesthesia with lidocain was significantly higher than when bupivacaine, prilocaine, or procaine were used. [18] Freedman's study identified other risk fac­tors for the development ofTNS besides lidocain: out­patient status, obesity and lithotomy position. [17]

4. Total spinal anaesthesia: Total spinal ana­esthesia can happen when there is unintentional intrath­ecal administration of local anaesthetics during epidu­ral or caudal anaesthesia. The onset is usually rapid. Patient exhibits signs of cardiovascular collapse in the form of severe hypotension, bradycardia and respira­tory insufficiency. Careful aspiration, use of test dose and incremental drug dosing can help avoid this com­plication. Iftotal spinal anaesthesia occurs, then pa­tients are put intratndlenburgposition so as to increase venous return, administer fluid along with inotropic sup­port to raise blood pressure, may need tracheal intu­bation to support ventilation. Fortunately need for se­dation during intubation and mechanical ventilation is minimal. At very high dose pupil may also dilate which come to normal size as the effect of local anaesthetic recedes.

5. Spinal or epidural hematoma: Epidural or spinal haematoma is a rare, but potentially disastrous complication of central neuraxial blocks. It was initially reported within 10 years after administration of first spinal anaesthetic. [19] The incidence of such hematomas has been estimated to be about 1:150,000 for epidural blocks and 1:220,000 for spinal anaesthetics. [20] Spinal hematoma is particularly catastrophic as it may go un­noticed until there is permanent neumlogic compromise. The variables associated with increased incidence spi­nal hematoma are; female gender, increased age, trau­matic needle /catheter placement, indwelling epidural catheter placement during, immediate preoperative, in­tra-operative and postoperative LMWH administra­tion. [21] Patient usually present with sudden new onset sharp back and leg pain with numbness, weakness, blad­der andbowel dysfunction. When spinal hematoma is suspected, neuro logic imaging (MRI and CT scan) and neurologic consultation should be immediately obtained. Good neurological recovery is seen in patients who have undergone surgical decompression within 8-12 hours.

6. Epidural abscess: Epidural abscess is a seri­ous complication after neuraxial block. The incidence varies from 0.015%to 0.7% according to different stud­ies. [22],[23] Although epidural abscess is uncommon, early diagnosis and treatment is paramount. Symptoms of epidural abscess usuallybegin several days after neural block, sometimes after months, include back pain, fe­ver, malaise, signs of cord compression including sen­sory changes, flaccid paralysis followed by spastic pa­ralysis, elevated blood leukocytes count, elevated cere­brospinal fluid protein and leukocytes. [22],[24] Clinical signs, duration of symptoms and the rate of neurological de­terioration show ahigh inter-individual variability, and the classic triad (spinal pain, fever and neurological defi­cit) is often not found, especiallynot at first presenta­tionto a physician. [25]

Gadolinium-enhanced magnetic resonance imag­ing is the most sensitive, specific and accurate imaging method [25],[26],[27] Staphylococci are the most frequent etio­logic agents (57%) followed by streptococci (18%) and gram negative bacilli (13%). [22] Associated risk factors are diabetes mellitus, chronic renal failure, epidural or systemic steroid injection, herpes zoster and chronic alcohol abuse.

The management of epidural abscess involve, drainage ofthe abscess and eradication ofthemicro­organism as the basic principles of therapy. Surgical therapy is the treatment of choice in the overwhelming majority of cases. Rapid surgical intervention is not only neededto minimize neurological damage, but also for controlling sepsis.. Duration of antimicrobial treatment is usually 4-6 weeksfor epidural abscess. [28]

7. Meningitis: Dural puncture maybe a risk for infection of subarachnoid space. Exact mechanism by which bacteria reaches to the central nervous system may not be known but the infectious source may be exogenous (e.g., contaminated equipment or medica­tion) or endogenous (a bacterial source in the patient seeding to the needle or catheter site). Microorgan­isms can also b e transmitted via a break in aseptic tech­nique, and indwelling catheters maybe colonized from a superficial site (skin) and subsequently serve as a wick for spread of infection from the skin to the epidural or intrathecal space. The s y mptoms appear hours to days after anaesthesia, sometimes onset time may be up to one month. [29] Initial clinical presentation are fever and headache, with backache with emesis, classical sign of meningism and lithargy. CSF is usuallyturbid with raised leukocytes, proteins and low glucose concentration. In great majority of cases the causative organism is al­pha-haemolytic streptococcus. [30] Lumbar puncture aids diagnosis. Give appropriate antibiotics early; which will usually be before the causative or its sensitivity is es­tablished. Use of steroid is debatable but recommended for community acquired meningitis. [31]

8. Arachnoiditis: Arachnoiditis, another rare complication of neuraxial anaesthesia may appear as transient nerve root irritation, cauda equina, and cones medullaris syndromes. It may show its presence later as radiculitis, clumped nerve roots, fibrosis, scarring dural sac deformities, pachymeningitis, pseudomeningocele, and syringomyelia, etc., all assocrated with arachnoiditis. Regarding regional anaesthe­sia in the neuraxis, arachnoiditis has resulted from epi­dural abscesses, traumatic punctures (blood), local anaesthetics, detergents, antiseptics or other substances unintentionally injected into the spinal canal. Patients usually presents with pain in the lower back, dysesthe­sia and numbness not following the usual dermatome di stribution. [32]

9. Cardiac Arrest: The incidence and causes of cardiac arrest related to anaesthesia in the perioperative period have been studied over two decades in many countries. [33],[34],[35] Majority of the literature regarding car­diac arrest relatedto regional anaesthesia involves ret­rospective studies or case reports. Few prospective surveys assessing a large number ofpatients have been published. [36] The incidence of cardiac arrest during re­gional anaesthesia varies in different studies and it ranges from 1.5-6.4110000 cases. [37],[38] Recently Charuluxananan et al reported the incidence of cardiac arrest following spinal anaesthesia is 2.73/10000 pa­tients. [39] Theories regardingthe mechanism by which neuraxial block contributes to cardiac arrest involve a circulatory aetiology. Initially sedation was speculated to have contributed to many ofthe cardiac arrests dur­ing spinal anaesthesia. [40] Another likely cause could be decrease in preload associated with neuraxial block resulting in a shift in cardiac autonomic balance toward the parasympathetic system leading to bradycardia. At least three mechanisms have been proposed, including activation of the low-pressure baroreceptors in the right atrium, the receptors within the myocardial pacemaker cells, andmechanoreceptors inthe leftventricle (stimu­lating a paradoxical Bezold-Jarisch response). In ad­dition, a high sympathetic level may directly favour va­gal tone; sedation, hypoxemia, hypercarbia, and chronic medications (such as [beta]-adrenergic antagonists) may contribute to the development and severity of brady­cardia. [41] Intravascular fluid administration, the admin­istration of mixed [alpha]- and [beta]-agonists, and vagolytic therapy have all been advocated to decrease the frequency of and improve the survival associated with cardiac arrest during neuraxial block. [42]

10. Urinary retention: Neuraxial anaesthesia blocking S2-S4 nerve root fibres decreases the uri­nary bladder tone and inhibits the voiding reflex. Uri­nary retention is common after anaesthesia and sur­gery, reported incidence of between 5% and 70%. Co morbidities, type of surgery, and type of anaesthesia influence the development of postoperative urinary re­tention (POUR). [43] Lower concentrations of local an­aesthetic are needed for paralysis of urinary bladder than motor nerves of lower extremities. Ultrasound has been shown to provide an accurate assessment of uri­nary bladder volume and a guide to the management of POUR. Recommendations for urinary catheterization in the perioperative setting vary widely, influenced by many factors, including surgical factors, type of anaes­thesia, co morbidities, local policies, and personal pref­erences. Inappropriate management of POUR may be responsible for bladder over distension, urinary tract infection, and catheter-related complications.

11. Drug Toxicity: Epidural anaesthesia can potentially produce local anaesthetic drug toxicity via uitravascular administration of drug in epidural vein. All local anaesthetic agents block neuronal voltage-gated sodium channels, and thus suppress conduction inpe­ripheral nerves. Systemic accumulation of local anaes­thetic agents may affect the functional integrity of these structures. All local anaesthetics can cause CNS toxic­ity and cardiovascular toxicity iftheir plasma concen­trations are increased by accidental intravenous inj ec­tion, with the CNS affected at lowerblood levels. With regard to CNS toxicitythe plasma levels necessaryto provoke CNS symptoms are to a large extent agent­specific. Initially, these toxic mechanisms are due to a selective blockade of cortical inhibitory neurons, which enables the formation of seizure potentials within sub cortical structures. Excitation of the CNS may be mani­fested by numbness of the tongue and perioral area, and restlessness, which may progress to seizures, res­piratory failure and coma. Treatment of CNS toxicity includes maintaining adequate ventilation and oxygen­ation, and controlling seizures with the administration ofthiopental sodium or benzodiazepines. Cardiovas­cular toxicity generally begins after signs of CNS toxicity have occurred. Bupivacaine and etidocaine ap­pear to be more cardio toxic than most other com­monly used local anaesthetics. Direct cardiac effects of local anaesthetics can be divided into (i) stereo specific inhibition of intracardial conduction and (ii) unspecific inhibition of myocardial energy supply and ion chan­nels. The corresponding spectrum ofsymptoms is not uniform and may range from extreme bradycardia, (ma­lignant) ventricular arrhythmia to refractory cardiac ar­rest [44] Treatment ofcardiovasculartoxicity depends on the severity of effects. Cardiac arrest caused by local anaesthetics should be treated with cardiopulmonary resuscitation procedures, but bupivacaine-induced dysrhythmias may be refractory to treatment. Injection of local anaesthetic through micro catheters and possi­bly small-gauge spinal needles results in poor CSF mix­ing and accumulation of high concentrations of local anaesthetic in the areas ofthe lumbosacral nerve roots. In contrast to bupivacaine, the hyperbaric lidocain (lignocain) formulation carries a substantial risk of neu­rotoxicity when given intrathecally. Reduction of he­patic blood flow by drugs or hypotension will decrease the hepatic clearance of amide local anaesthetics. Spe­cial caution must be exercised in patients taking digoxin, calcium antagonists and/or beta-blockers. [45]

Controversies Regarding Regional Anaesthesia:

Despite using the neuraxial block for so many years, the controversies related to the appropriate use of these blocks still remains are as follows:

1. Regional anaesthesia for outpatients: Ear­lier it was believed that regional anaesthesia was not fit for outpatient anaesthesia; however, an ever increas­ing number of day-case surgical patients are putting up a challenge on the existing methods of anaesthesia for day care procedures. `Walk-in, walk-out' spinals with an extremely low dose of lidocain and opioids for gynaecological laparoscopy created the concept of selective spinal anaesthesia. Reintroduction of chlo­roprocaine mayprovide asolutionforbilateral, short­acting spinal anaesthesia in the future. To produce re­liable spinal anaesthesia with a reasonable recovery time it is essential to understand the factors affecting the spread of spinal block and to choose the optimal drug and adequate dose for specific surgical proce­dures. [46]

2. Epidural test dose: In epidural anaesthesia a large volume of local anaesthetic is used, which if in­jected intrathecally or intravascularly, can cause signifi­cant toxicity. So the classical epidural test dose com­bining 3 ml of 1.5% lidocain with 1:200,000 epineph­rine is used. Most controversy surrounds the use of test dose in obstetric patients, in whom blood flow to the uterus may be decreased by intravascular injection, thereby jeopardizingthe foetus. [47] Epidural test dose may not be reliable in patients on (3-blockers or in pa­tients undergoing epidural catheter placement under general anaesthesia. At times aspiration may produce false negative results. Recently Mhyne et al, evaluated the different strategies proposed to minimize the inci­dence of epidural vein cannulation during lumbar epi­dural catheter placement in pregnantwomen, and con­cluded that this risk could be reduced with the lateral patient position, fluid pre-distension of the epidural space, a single orifice catheter, a wire-embedded poly­urethane epidural catheter and limiting the depth of cath­eter insertion to < 6 cm. [48] Norris et al proposed that there was no justification in administering test dose in patients where aspiration was negative [49] Still many cli­nicians follow the golden rule of initial aspiration and incremental doses of local anaesthetics.

3. Use of neuraxial block in infected or fe­brile patients: Use of single shot spinal or short term epidural anaesthesia poses little risk to the patient who may become transiently bacteramic during surgery. Conversely neuraxial blocks in infected orfebrile pa­tients may increase the risk ofneuraxial infection, and these blocks remain controversial. Most authorities believe that neuraxial blocks should not be performed in patients who are bacteramic. Conservatively, all pa­tients with an established local or systemic infection should be considered at risk for developing infection of the CNS. Available data suggest that:

Serious central neuraxial infections such as arach­noiditis, meningitis, and abscess after spinal or epidural anaesthesia are rare. The decision to perform a regional anaesthetic technique must be made on an individual basis considering the anaesthetic alternatives, the ben­efits of regional anaesthesia, and the risk of CNS in­fection (which may theoretically occur in any bacteramic patient). Despite conflicting results, many experts sug­gest that, except in the most extraordinary circum­stances, central neuronal block should not be performed in patients with untreated systemic infection. Available data suggest that patients with evidence of systemic in­fection maysafely undergo spinal anaesthesia, provided appropriate antibiotic therapy is initiated before dural puncture and the patient has shown a response to therapy, such as a decrease in fever (placement of an indwelling epidural (or intrathecal) catheter in this group of patients remains controversial). Adelay in diagnosis and treatment of major CNS infections of even a few hours may significantly worsen neurologic outcome. [50]

4. Neuraxial anaesthesia for immuno corn­promised patients: Neuraxial anaesthesia and anal­gesia are advantageous over systemic opioids in pro­viding better analgesia, reduced pulmonary complica­tions and reduced graft occlusion. In addition, neuraxial analgesia may decrease the risk of infection through attenuation of the stress response and preservation of immune function. [51] Despitethese benefits, patients with altered immune status because of neoplasm, immuno­suppression after solid organ transplantation, and chronic infection with human immunodefrciency virus (HIV) or herpes simplex virus (HSV) are often not considered candidates for neuraxial techniques because of the risk of infection around the spinal cord or within the spinal canal. A depressed immune state increases both frequency and severity of infection. The relative risk of central nervous system (CNS) infections in pa­tients with altered immune status compared with the normal host is unknown but still Horlocker et al sug­gests thatthe decision to perform aregional anaesthetic technique must be made on an individual basis consid­ering the anaesthetic alternatives, the benefits of regional anaesthesia, and the risk of CNS infection (which theo­retically are more likely to occur in the immuno com­promised patient), as well astheriskofhemonhagic or neurologic complications. [52]

The attenuated inflammatory response within the immuno compromised patient may diminish the clinical signs and symptoms often associated with infection. Likewise, the range of microorganisms causing inva­sive infection inthe immuno compromised host is higher thin that affecting the general population and includes atypical and opportunistic pathogens. Consultation with an infectious disease specialist is advised to facilitate initiation of early and effective therapy.

A delay in the diagnosis and treatment of CNS infections worsens neurologic outcome and increases mortality. There are inadequate data available regard­ing the safety of spinal and epidural anaesthesia in the presence of primary Herpes simplex virus-2 infection. However, viremia, fever, and meningitis have been re­ported. These findings would suggest a conservative approach. Central neuronal block has been shown to be safe in patients with recurrent HS V infections, al­though exacerbations ofHSV 1 have been reported in association with intrathecal and epidural opioids. Mini­mal data suggest that neuraxial and peripheral techniques (including epidural blood patch) can be performed safely in HIV infected patients. The presence of pre­existing neurologic pathology is common inthese pa­tients and must be considered [52]

5. Neuraxial blocks in neurological disorder. Historically, the use of regional anaesthetic techniques in patients with pre-existing central nervous system (CNS) disorders has been considered relatively con­traindicated. The fear of worsening neurologic outcome secondaryto mechanical trauma, local anaesthetic tox­icity orneural ischemiais commonly reported. Many clinicians completely avoid neuraxial block in patients with pre-existingneurologic disorder because of medico legal implications ofany increase in postoperative neu­rologic deficit. Many earlier studies proposed that there is exacerbation of neurological deficit after regional anaesthesia, Horlocker [53] et al conducted a retrospective review and analysed thatthe decision to perform regional anaesthesia inpatients with pre-existing neu­rologic deficits should be based on the risks and po­tential benefits of each individual case. He concluded that the risks commonly associated with neuraxial ana­esthesia and analgesia in patients with pre-existing CNS disorders may not be as frequent as once thought and that neuraxial blockade should not be considered an absolute contraindication within this patient population.

6. Neuraxial blocks in diabetic patients: Pe­ ripheral sensory motor neuropathies may occur sec­ondaryto a variety of underlying aetiologies, including metabolic, autoimmune, infectious, orhereditary ab­normalities. Of these aetiologies, diabetes mellitus is the most common cause of systemic polyneuropathy. The frequency of diabetic polyneuropathy ranges from 4% to 8% at the time of initial presentation, to approxi­mately 50% in patients with chronic disease. Ultimately, all asymptomatic patients will likely be found to have abnormalities ofnerve conduction. [54] Patients with un­derlying, chronic neural compromise secondary to is­chemic (peripheral vascular disease or micro angi opathy), toxic (chemotherapy), or metabolic (diabetes mellitus) abnormalities maybe at an increased risk of further neurologic injury because of aphysiologic "double-crush." The pathophysiology of diabetic poly­neuropathy is multifactorial and not completely under­stood. Any disruption in the supply of essential com­ponents (blood, oxygen, adenosine triphosphate, glu­cose) to the axon can cause distal axonal degenera­tion. There are several types of neuropathies associ­ated with diabetes, each classified into a distinct clini­cal syndrome. Distal symmetric sensorimotor polyneur­opathy is the most common syndrome, and is often considered synonymous with the term diabetic neur­opathy. It has been suggested that when compared with the general population, patients with pre-existing neu­ral compromise, including peripheral sensorimotor neu­ropathy and diabetic polyneuropathy; maybe at an in­creased risk of perioperative nerve damage after re­gional blockade. [55] Abnormal local anaesthetic diffusion and subsequent neurotoxicitymay have been the con­tributing factors to the neurological complications. Tox­icity differs greatly among local anaesthetics, bupivacaine being the least toxic. Even though hyper­baric lidocaine is most often associated with neurotox­icity, all local anaesthetics are potentially neurotoxic. [56] Using rats injected with streptozotocinto induce dia­betes, Kalichman et al concluded that local anaesthetic requirements are decreased in diabetic animals, and therefor the risk of local anaesthetic toxicity and sub­sequent nerve injury is increased. [57] Finally, it is pos­sible that epinephrine may have a pathogenic role in the development of neurotoxicity after regional anaesthe­sia. Epinephrine alone, or when combined with a local anaesthetic, may significantly reduce nerve blood flow. Although there is no human study to confirm the de­creased requirement of local anaesthetics in neuraxial blocks in diabetic neuropathy patients; however, the risk appears to be higherthan that reported forhhe gen­eral population. Clinicians should be aware ofthis po­tentially high-risk subgroup ofpatients when develop­ing and implementing a regional anaesthetic care plans. [58]

7. Premedication with benzodiazepines: There is widely held belief that benzodiazepines should be used with neuraxial anaesthesia to decrease the sys­temic toxicity by elevating seizure threshold. But data indicates that resuscitation may become more difficult after cardiovascular collapse after bupivacaine if diaz­epam is used as premeditation.

8. Neuraxial blocks in patients receiving an­ticoagulants: Numerous studies have documented the safety ofneuraxial anaesthesia and analgesiain the an­ticoagulated patient. Patient management is based on appropriate timing of needle placement and catheter removal relative to the timing of anticoagulant drug ad­ministration.

The rarity of spinal hematoma defies a prospec­tive-randomized study, and there is no current labora­tory model. As a result, these consensus statements represent the collective experience of recognized ex­perts in the field of neuraxial anaesthesia and antico­agulation. They are based on case reports, clinical se­ries, pharmacology, haematology; and risk factors for surgical bleeding. The decision to perform spinal or epidural anaesthesia/analgesia andthe timing of cath­eter removal in a patient receiving antithrombotic therapy should be made on an individual basis, weigh­ing the small, though definite risk of spinal hematoma with the benefits of regional anaesthesia for a specific patient. Vigilance in monitoring is critical to allow early evaluation of neurologic dysfunction and prompt inter­vention. We must focus not only on the prevention of spinal hematoma, but also optimization ofneurologic outcome. [59][Additional file 1]

Neuraxial anaesthetic techniques remain an im­portant part of anaesthesiologist's armamentarium. Depending on specific patient factors and the setting in which these techniques are applied, they may offer sig­nificant advantages. The occurrence of any complica­tion implies an interaction of factors related to the block­ade itself and known or unknown pre-existing condi­tions in the patient. Fortunately, neuraxial techniques are associated with a low incidence of significant com­plications. However, as over all perioperative safety improves, rare and potentially devastating complica­tions from neuraxial anaesthesiabecome more signifi­cant. Anaesthesiologists can minimise the risk ofthese complications by appropriately applying neuraxial tech­niques in carefully selected patients. Proper patient selection depends on detailed knowledge of any condi­tions that may predispose patients to complications from neuraxial techniques. Regarding controversies in re­gional anaesthesia variances from recommendations con­tained here may be acceptable based on the j udgment of the responsible anaesthesiologist. The consensus statements are designed to encourage safe and quality patient care but cannot guarantee a specific outcome. They are also subject to timely revision as justified by evolution of information and practice. Finally, the in­vestigation does suggest thatthe risks commonly asso­ciated with neuraxial anaesthesia in patients with pre­existing CNS disorders, inumunocompromised patients, patients with infection, patients on anticoagulants and diabetic patients, may not be as frequent as once thought. In fact, it may be prudent to reconsider the long-stand­ing beliefthat neuraxial anaesthesia be considered an absolute contraindication within this patient population. However, to make definitive conclusions on the safety of these techniques in these patients require further prospective study.

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