EPIDURAL

EMERGENCY MANAGEMENT

Question the patient, reassure and sedate if appropriate.
Inform the surgeon as to the nature of the problem
Complete AB COVER CD - A SWIFT CHECK
If hypotensive (1)
If bradycardic (1)
Do not hesitate to treat as Cardiac Arrest (1)

Review and treat probable causes: (2)
     Inadequate fluid loading, blood loss
     High block (aspirate CSF from epidural?)
     Drug errors:
                        Wrong drug, concentration or volume
                        Wrong site/route
                        Incorrect infusion rate
        Ensure fluid, drug, infusion rates and site/route are correct

For suspected local anaesthetic toxicity (3)
     Give IV phenytoin 15 mg/kg over 30 minutes for CNS irritability
     Control seizures with 1 - 2 mg/kg of IV thiopentone, but beware of cardiovascular compromise
     For cardiovascular collapse, treat as Cardiac Arrest (1)

Assess the block (2), (4), (5)
     If inadequate consider
          general anaesthesia,
          OR local infiltration
          OR further local anaesthetic down the epidural catheter (2), (4)
     If excessive, administer oxygen and assist ventilation if required (3), (5)

Consider needle/catheter problem (6), (7), (8)
     Wrong site:     - inadvertent intravascular placement/injection
                           - inadvertent intrathecal placement/injection
                           - inadvertent intrapleural placement/injection
     Trauma          - haematoma
                          - nerve damage
                          - pneumothorax
                          - pain
     Beware of tourniquet failure with Bier's blocks

FURTHER CARE

Confirm and correct cause
Review patient to determine delayed events (5), (6)
Counsel the patient, arrange follow up

NOTES:
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There were 252 reports involving regional anaesthesia in the first 4000 AIMS anaesthesia incidents. Of these 78% were either epidural or spinal anaesthesia related.
(1) Hypotension and arrhythmia in spinal/epidural incidents reported accounted for 30% of all regional anaesthesia incidents, and 2% of all deaths. They involved a combination of high block and/or hypovolaemia.
(2) Common precipitants included:
          -Inadequate time for assessment
          -Elderly patients with multiple medical problems
          -Usual dosages of local anaesthetics having a more profound effect in the elderly.
          -Error in judgement of level of block and or blood loss
(3) Local anaesthetic toxicity was reported in 10% of all cases with convulsions in one third of these
(4) Failed blocks - 5% of all regional anaesthesia incidents.
(5) Overdose/total spinal - 10% of all regional anaesthesia incidents.
     Most common problems cited included:
          Dural puncture - unintended - 13% of all reports
          Post dural puncture headache - 52% of dural punctures,
                                                          with 75% of these requiring a blood patch.
Miscellaneous problems of epidurals: abscess, haematoma,
                                                        subarachnoid migration, and prolonged recovery.
(6) Trauma, infection or pain was reported in 6% of cases
(7) Intravascular injection was reported in 4% of the epidural/spinal blocks
(8) Inadvertent epidural injection of IV drugs in 3 reports
      (metaraminol 2, ranitidine 1) without sequelae.

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Regional Anaesthesia 1

EPIDURAL/SPINAL