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By: Dr.roushanfekr/anesthesiologist

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1--------NEUROLOGIC: Paraplegia Cauda Equina Syndrome Epidural Hematoma Nerve Injury PostDural Puncture Headache Transient Neurologic Symptoms 2--------CARDIOVASCULAR: Hypotension Bradycardia Cardiac Arrest 3--------- RESPIRATORY 4-------INFECTION 5-------BACKACHE 6-------NAUSEA AND VOMITING 7-------URINARY RETENTION 8-------PRURITUS 9-------SHIVERING

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The physiologic effects of neuraxial blocks may be misinterpreted as complications Serious neurologic complications are rare The true incidence of most neurologic injury is unknown

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The frequency 0.1 per 10,000 the mechanism: 1. direct needle trauma to the spinal cord 2. the injection of a foreign substance into the CSF 3. Contamination by the descaling liquid used to cleanse the procedure 4. the chloroprocaine neurotoxicity 5. Adhesive arachnoiditis, cauda equina syndrome to be related to a combination of low pH and the antioxidant sodium bisulfite preservative 6. Profound hypotension or ischemia of the spinal cord 7. Anterior spinal artery syndromepainless loss of motor and sensory function with sparing of proprioceptionby the posterior column The anterior cord vulnerable to ischemic single and tenuous source of arterial blood supply (Adamkiewicz) Ischemia caused profound hypotension,mechanical obstruction, vasculopathy, or hemorrhageirreversible anterior cord damage

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The rate 0.1 per 10,000 The lumbosacral roots vulnerable to direct exposure of large doses of LA: a single injection of highly concentrated LA (5% lidocaine) prolonged exposure to a LA through a continuous catheter spinal catheters smaller than 24 G( headache) : 1- to pooling of LA around the lumbosacral nerve roots 2- slow injectate flow through the fine-bore catheter: exposing them to high concentrations of LA

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the rates 0.06/10,000 after SA after EA tenfold higher

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risk factors including : 1. Difficult or traumatic needle or catheter insertion 2. coagulopathy 3. elderly age 4. female gender commonly features: Radicular back pain,prolonged blockade longer and bladder or bowel dysfunction should prompt MRI on an urgent basis

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rate of radiculopathy or paresthesia or peripheral neuropathy EA CSE SA in adults for the purposes of perioperative anesthesia or analgesia in the obstetric, pediatric, and chronic pain settings difficult to determine because investigation, diagnosis, causation, outcomes are highly variable. SA-EA (0.1 per 10,000) CSEs (0.2 per 10,000), mostly in young, healthy patients.

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A relatively common complication to result from puncture of the dura membrane: neuraxial anesthesia after myelography diagnostic lumbar puncture 1. First, the loss of CSF through the dura traction on pain-sensitive intracranial structures 2. Alternatively, the loss of CSF compensatory painful intracerebral vasodilation to offset the reduction in intracranial pressure

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The characteristic feature: a frontal or occipital headache that worsens with the upright or seated posture and is relieved by lying supine Associated symptoms : nausea, vomiting, neck pain, dizziness, tinnitus, diplopia, hearing loss, cortical blindness, cranial nerve palsies, and even seizures. In more than 90% of cases, the onset of characteristic symptoms within 3days of the procedure, 66% start within the first 48h Spontaneous resolution usually within 7 days in the majority (72%) of cases, whereas 87% of cases resolve by 6 months

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Factors That Can Increase the Incidence of Headache After Spinal Puncture 1. Age: Younger, more frequent 2. Sex: Females > males 3. Needle size: Larger > smaller 4. Needle bevel: Less when the needle bevel is placed in the long axis of the neuraxis noncutting needle cutting 5. Pregnancy: More when pregnant 6. Dural punctures: More with multiple punctures Factors That Do Not Increase the Incidence of Headache After Spinal Puncture 1. Insertion and use of catheters for continuous spinal anesthesia 2. Timing of ambulation

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Conservative management : 1. supine positioning 2. hydration 3. caffeine 4. and oral analgesics. 5. Sumatriptan has also been used with varying effect but is not without side effects

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Epidural blood patch definitive therapy its safety and efficacy well-documented a single epidural blood patch 90% initial improvement rate persistent resolution 61% to 75% of cases

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ideally performed 24 hours after dural puncture and after the development of classic symptoms prophylactic epidural blood patching??? the direction of spread was preferentially cephalad A recent multinational, multicenter, randomized, blinded trial suggested that 20 mL of blood is a reasonable starting target volume blood will spread over a mean distance of nine spinal segments A second patch may be performed 24 to 48 hours after the first in the case of ineffective or incomplete relief of symptoms

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after intrathecal administration of every LA (Traditionally,lidocaine) SA is usually characterized: 1. bilateral or unilateral pain in the buttocks legs or, less commonly, isolated buttock or leg pain. 2. Symptoms occur within 24 hours of the resolution of SA 3. not associated with any neurologic deficits or laboratory abnormalities 4. mild to severe pain and typically resolves spontaneously in 1 week or less highest after intrathecal lidocaine and mepivacaine and is far less frequent with bupivacaine The type of needle reduced by a double-orifice needlesingle- orifice injecting anesthetic caudally in the thecal sac not commonly with epidural procedures(occurred with lidocaine) commonly the lithotomy position NSAID the first line of treatment,but pain severe even require opioids.

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in SA hypotension (defined as SBP30%) is associated with: chronic alcohol consumption,history of hypertension, BMI, and the urgency of surgery. TREATMENT: 1. prevention of hypotension caused by vasodilatation by a prophylactic (preloading) 2. infusion of colloid or crystalloid during the performance of the neuraxial block (coloading) 3. this is no longer recommended as a routine practice.

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blockade of the thoracic sympathetic fibers (preganglionic cardiac accelerator fibers at T1-T5) reflexive slowing of the HR as vasodilation reduces the venous return to the RA stretch receptors exaggerated bradycardia(40 to 50) : 1. baselineHR 60 2. age 37 years 3. male gender 4. nonemergency status 5. -adrenergic blockade 6. prolonged case duration Severe bradycardia (