NAP3 2009: Neuraxial Complications

(See Learning Points slides at the end)

Summary:

List of disasters	· Vertebral canal haematoma · Spinal cord ischaemia · Nerve and spinal cord injury · Abscess · Meningitis · Subdural haematoma · Total spinal · Cardiovascular collapse
Biggest disasters	· Paraplegia or death: 1 in 50-100k · Permanent nerve injury: 1 in 25-50k
High risk groups	· Frail + elderly + major surgery + epidural (haematoma) · Anticoagulated (haematoma) · Immunocompromised (infection, abscess)
Prognosis	· 2/3 “severe injuries” resolve · Canal haematoma and cord ischaemia cause lasting damage

· Fail to monitor neurology

· Fail to take limb weakness seriously. Red flags include

o Thoracic epidural + weakness

o Unexpectedly dense motor block

o Not resolved after 4 hours cessation

· Fail to get MRI ASAP when indicated

· Fail to contact neurosurgery ASAP when indicated

Vertebral canal haematoma	· 50% develop upon removal of epidural catheter
Spinal cord ischaemia	· Hypotension contributes · MRI may not pick it up
Abscess	· May present after discharge · May presents as sepsis without localizing symptoms or signs · Material risk if >2 days, higher risk if >5-7 days
Obstetrics	· Post-neuraxial headache is probably simple PDPH · But beware SDH and meninigitis if a) multiple attempts b) atypical headache · Failed epidural top up followed by spinal causes unpredictable block height. Do CSE.
Wrong route	· Most common in obstetrics · Keep trays separate · Keep local connected to epi, or chuck it out (my note)
Cardiovascular collapse	· Must have IV fluid and vasoactives available if doing neuraxial · Don’t do neuraxial in a hypovolaemic patient (my note)
Miscellaneous	· CSEs are overrepresented in complications and we don’t know why