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Ấn bản này toàn diện hơn nhiều so với những nỗ lực trước đây của chúng tôi và bao gồm hơn và có nhiều trang, bảng, sơ đồ và hình minh họa màu hơn. Văn bản này cũng được tham chiếu một cách toàn diện. Như trong các lần xuất bản trước, có một số lặp lại và đó là điều không thể tránh khỏi. Tuy nhiên, thật thú vị khi so sánh kinh nghiệm của các bác sĩ gây mê từ khắp nơi trên thế giới và từ bên ngoài chuyên ngành của chúng tôi. Độc tính toàn thân của thuốc gây mê cục bộ (CUỐI CÙNG) là một chủ đề rất phổ biến đối với tất cả những người thực hành Gây mê cục bộ và vùng, và chúng tôi đã học được rất nhiều về cách phòng ngừa và điều trị căn bệnh này trong 30 năm qua. May mắn thay, hầu hết các biến chứng mà chúng tôi đã thảo luận là rất hiếm và chúng tôi thường xuyên phải gánh chịu trách nhiệm cho những chấn thương mà chúng tôi không gây ra ngay từ đầu. Trọng tâm chính của chúng tôi là an toàn và phòng ngừa thương tích trong thực hành gây tê cục bộ và khu vực, và chúng tôi đã kêu gọi nhiều chuyên gia từ khắp nơi trên thế giới chia sẻ kinh nghiệm của họ với chúng tôi. Chúng tôi hy vọng bạn đánh giá cao những thay đổi mà chúng tôi có và như mọi khi, chúng tôi hoan nghênh các phê bình và đề xuất của bạn để cải thiện. Có một thay đổi quan trọng khác mà tôi đã thực hiện trong ấn bản này và đó là tôi đã mời đồng nghiệp và bạn bè của tôi từ Khoa Gây mê và Y học Đau từ Đại học Alberta cùng biên tập ấn bản này của văn bản với tôi. Ông đã đóng góp rất nhiều vào kiến thức của chúng tôi về gây tê cục bộ và khu vực trong hai thập kỷ qua và đã giúp rất nhiều cho phiên bản mới nhất này.
Brendan T Finucane Ban C.H Tsui Editors Complications of Regional Anesthesia Principles of Safe Practice in Local and Regional Anesthesia Third Edition 123 Complications of Regional Anesthesia www.ajlobby.com Brendan T Finucane • Ban C.H Tsui Editors Complications of Regional Anesthesia Principles of Safe Practice in Local and Regional Anesthesia Third Edition www.ajlobby.com Editors Brendan T Finucane, MB, BCh, BAO, FRCA, FRCPC Department of Anesthesiology and Pain Medicine University of Alberta Edmonton, AB, Canada Ban C.H Tsui, MSc (Pharm), MD, FRCPC Department of Anesthesiology, Perioperative and Pain Medicine Stanford University School of Medicine Stanford, CA, USA Originally published by Churchill Livingstone, New York City, 1999 ISBN 978-3-319-49384-8 ISBN 978-3-319-49386-2 (eBook) DOI 10.1007/978-3-319-49386-2 Library of Congress Control Number: 2017933835 © Springer International Publishing AG 2007, 2017 This work is subject to copyright All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed The use of general descriptive names, registered names, trademarks, service marks, etc in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations Printed on acid-free paper This Springer imprint is published by Springer Nature The registered company is Springer International Publishing AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland www.ajlobby.com We would like to dedicate this edition of the book to our patients, our teachers, our students, and our families Brendan T. Finucane, MB, BCh, BAO, FRCA, FRCPC Ban C.H. Tsui, MSc (Pharm), MD, FRCPC www.ajlobby.com Preface We are now ready to publish the third edition of Complications of Regional Anesthesia which was first published 17 years ago The title remains the same but we have added the subtitle, Principles of Safe Practice in Local and Regional Anesthesia, to stress the relatively new emphasis and importance on safety and prevention and to broaden our horizons to include some discussion about the practice and the administration of not just Regional but also Local Anesthesia We have made some significant changes to the book which we hope you approve First of all this is a much more comprehensive edition going from 24 to 35 chapters, and we have also divided the book into seven separate parts based mostly on logic In the opening part entitled General considerations, we started out with a chapter on the History of Regional Anesthesia which seemed like a good place to start We also addressed the issue of Safety of Regional Anesthesia It is difficult to discuss much about regional and local anesthesia without mentioning toxicity of local anesthetics which has been a problem with regional and local anesthesia since its inception more than 130 years ago, and we finished up that section with a good discussion of Outcomes comparing Regional and General Anesthesia In the second part we addressed Special considerations, which includes a chapter on Mechanisms of Nerve injury, Infection, Catheter techniques, and the whole issue of regional anesthesia in the presence of neurologic disease and how to evaluate neurologic injury following regional anesthesia We then dedicated several chapters to Specific blocks involving anatomic regions of the body specifically addressing safety and management of adverse events We dedicated the next part to specific Patient Populations—the young, the old, the pregnant, obese, and those suffering from chronic pain The next part is new territory for us and is entitled Special Environments We invited a group of practitioners, mostly surgeons, who frequently use local anesthetics in their practices, to share their expertise and experiences with us Among this group of specialists are dentists, ophthalmologists, emergency room physicians, orthopedists, and plastic surgeons We have a lot to learn by sharing our experiences using local and regional anesthesia with specialists outside our own discipline and they from us We dedicated a part to Morbidity Studies and this part includes writers from across the world adding an International flavor, as we are sometimes accused of being too insular in North America We dedicated the final part to Medical Legal Aspects of Local and Regional Anesthesia, which we must realistically face in the modern world of this twenty-first century Labat, in the 1920s, was the first fully trained specialist in Regional Anesthesia, and he influenced the leaders of this new emerging specialty of anesthesiology to use regional anesthesia in their practices Most anesthesiologists at that time opted for general anesthesia because of its predictability Tremendous advances have been made in Regional Anesthesia in the past 30 or 40 years, so much so that most anesthesiologists in the modern era have become interested in regional anesthesia again because there is far more predictability in the practice of regional anesthesia than ever before We can now actually see what we are doing instead of blindly seeking neural targets, based on our knowledge of anatomy Most anesthesiologists fully appreciate the enormous benefits of regional anesthesia to patients especially in the postoperative period but also long term However, despite good practice, we encounter problems vii www.ajlobby.com viii Preface and unforeseen circumstances, so practitioners must be fully aware of the many pitfalls and complications associated with the practice of regional anesthesia even though we have made enormous advances in recent years This edition is much more comprehensive than our previous efforts and more inclusive and there are more pages, tables, diagrams, and colored illustrations This text is also comprehensively referenced As in previous editions, there is some repetition and that is inevitable However, it is refreshing to compare anesthesia practitioners’ experiences from around the world and from outside our own discipline Local Anesthetic Systemic Toxicity (LAST) is a very common theme among all who practice Local and Regional Anesthesia, and we have learned a lot about prevention and treatment of this malady in the past 30 years Fortunately most of the complications we have discussed are rare and all too often we appear to shoulder the blame for injuries that we did not cause in the first place Our main emphasis is on safety and prevention of injury in the practice of local and regional anesthesia, and we have called upon a great variety of experts from around the world to share their experiences with us We hope you appreciate the changes we have and as always we welcome your critique and recommendations for improvement There is one other important change I have made in this edition and that is I have invited my colleague and friend from the Department of Anesthesiology and Pain Medicine from the University of Alberta to co-edit this edition of the text with me He has contributed enormously to our knowledge of local and regional anesthesia in the past two decades and helped a great deal with this latest version Edmonton, AB, Canada Stanford, CA, USA Brendan T. Finucane Ban C.H. Tsui www.ajlobby.com Acknowledgments We would like to express our deep gratitude to all of the contributors to this text We are impressed by the quality of the material presented and their willingness to abide by all of the rules imposed We also wish to thank a group of students, medical students, fellows, and research assistants over the past years, including Gareth Corry, Saadat Ali, and Jeremy Tsui, who assisted in organizing the written material An investigator grant from the Alberta Heritage Foundation for Medical Research allowed Dr Tsui to pursue this project by helping to support his academic work Acknowledgments Brendan T. Finucane, MB, BCh, BAO, FRCA, FRCPC I would like to acknowledge some special individuals who greatly influenced my career in anesthesia, academic medicine, and my passion for regional anesthesia These are Dr John Shanahan, Dr Tom Bryson, Professors T Cecil Gray, John E Steinhaus, Evan Frederickson, Pritvi Raj, and Ben Covino Acknowledgments Ban C.H. Tsui, MSc (Pharm), MD, FRCPC To my wife, Eliza, and my children, Jenkin and Jeremy—the real loves of my life Without their support and understanding, I could not have completed this demanding project I would also like to dedicate this opus to my parents, Woon-Tak and Kau-Wan, for their love and guidance throughout my life Brendan T. Finucane Ban C.H. Tsui ix www.ajlobby.com Contents Part I General Considerations The History of Local and Regional Anesthesia Brendan T Finucane Regional Anesthesia Safety 15 John W.R McIntyre and Brendan T Finucane Local Anesthetic Toxicity: Prevention and Management 41 Derek Dillane Outcome Studies Comparing Regional and General Anesthesia 55 Brian O’Donnell and Michael O’Sullivan Part II Special Considerations Nerve Injury Resulting from Intraneural Injection When Performing Peripheral Nerve Block 67 Rakesh V Sondekoppam and Ban C.H Tsui Regional Anesthesia in the Presence of Neurologic Disease 103 John Shepler, Andrea Kattula, and George Arndt Evaluation of Neurologic Injury Following Regional Anesthesia 113 Quinn Hogan, Keith McCollister, Matthew Harmelink, Laura Kohl, and Michael Collins Regional Anesthesia and Anticoagulation 139 Robert B Bolash and Richard W Rosenquist Infection in Association with Local and Regional Anesthesia 149 Terese T Horlocker, Denise J Wedel, and Adam D Niesen 10 Continuous Peripheral Nerve Blocks Safe Practice and Management 167 Geert-Jan van Geffen and Jörgen Bruhn Part III Specific Regional Blocks: Safe Practice and Management of Adverse Events 11 Complications of Regional Anesthesia: Upper and Lower Extremity Blockade 189 Stephen Choi, Patrick B.Y Wong, Kristen Gadbois, and Colin J.L McCartney 12 Complications of Thoracic Wall Regional Anesthesia and Analgesia 199 Christine Lee and F Michael Ferrante xi www.ajlobby.com xii Contents 13 Abdominal Wall Blocks: Safe Practice and Management of Adverse Events 219 James D Griffiths and Peter D Hebbard 14 Epidural Blockade: Safe Practice and Management of Adverse Events 227 Steven J Gaff 15 Spinal Anesthesia: Safe Practice and Management of Adverse Events 245 Pekka Tarkkila Part IV Specific Patient Populations: Safe Practice and Management of Adverse Events 16 Complications of Regional Anesthesia in Chronic Pain Therapy 261 David Flamer, Rachael Seib, and Philip W.H Peng 17 Local and Regional Anesthesia in the Elderly 287 Ferrante S Gragasin and Ban C.H Tsui 18 Local and Regional Analgesia for Labor and Delivery 303 Yoo Kuen Chan and Peng Chiong Tan 19 Local and Regional Anesthesia in the Obese Patients 319 Hendrikus J.M Lemmens 20 Local and Regional Anesthesia in Pediatrics 327 Belen De Jose Maria Part V Special Environments: Safe Practice and Management of Adverse Events 21 Local and Regional Anesthesia in Dental and Oral Surgery 341 Stanley F Malamed, Kenneth L Reed, Amanda Okundaye, and Andrea Fonner 22 Local and Regional Anesthesia in the Emergency Room 359 Andrew A Herring 23 Recognizing and Mitigating Risk of Ophthalmic Regional Anesthesia 369 Brad Wakeman, Robert William Andrew Machuk, Rizwan Somani, Dean Y Mah, and Ian M MacDonald 24 Local Infiltration Analgesia for Orthopedic Joint Surgery 381 Sugantha Ganapathy, James L Howard, and Rakesh V Sondekoppam 25 Local and Regional Anesthesia in Plastic Surgery: Safety Considerations and Management of Adverse Events 399 John Mesa, Don Lalonde, and Luis O Vasconez Part VI Morbidity Studies: International Perspective 26 Development and Methodology of a Registry of Regional Anaesthesia 413 Michael J Barrington 27 Australia: Results of a Multicenter Registry of Regional Anesthesia 421 Michael J Barrington 28 Canada: Medical Legal Aspects of Regional Anesthesia Practice 429 Kari G Smedstad and Brendan T Finucane www.ajlobby.com 487 35 Medical Legal Aspects of Regional Anesthesia: Legal Perspective then the claimant can use them to argue that the care provided fell below the standard expected at law The guidelines are used in this way as evidence of what a responsible body of medical practitioners considers a reasonable standard of care and therefore an independent marker of safe practice Practicing outside the guidelines will not however necessarily be sufficient for a claimant to prove a breach of duty There may be a number of grounds on which the anesthetist can argue that the guidelines should not be followed, or at least should not have been followed in that particular case An example of a claim founded on practice outside the guidelines appeared in a 2012 editorial in the British Journal of Anaesthesia [9] In that case, the patient suffered a very rare complication of a central line insertion (a fistula between the internal jugular and the vertebral artery), resulting from an inadvertent arterial puncture during insertion of a central line without ultrasound guidance She was left with a small visual field defect after the repair of the fistula Two years before the incident, the National Institute of Clinical Excellence (NICE) guidelines had recommended that all central lines be placed under ultrasound guidance The patient, citing failure to follow the NICE guideline, sued for malpractice, arguing the complication may have been avoided if the guidelines had been followed The anesthetist’s counsel argued that the approach chosen “was a recognised technique, the one he was most familiar with and therefore the technique that would be expected to minimise the risk of harm to the patient” [9] and that a significant number of other anesthetists were practicing that way The defence also referred to the fact that implementing guidelines within 3 months of publication (as is recommended for NICE guidelines) is not always possible in reality The claimant withdrew the case We not know why but we can speculate that, having heard the evidence that supported deviation from the guidelines, the claimant was not confident of success The case illustrates that deviation from a guideline can be defended by justifying an alternative technique and the practical difficulty of implementing the guideline Another means of justifying deviation from the guideline is to directly discredit the guideline This would involve calling expert evidence that the guidelines are out of date or not supported by “… the rigorous methodology that would justify the authority they profess to hold, be this in terms of their influence on clinical practice, or their use in establishing legal standards” [9] Additionally, if in a group practice, evidence of discussion about this topic, and a group decision to practice outside the guidelines and reasons for doing that would be evidence that may help persuade a decision-maker that a reasonable standard of care had been provided The more well recognized the guidelines are, the more difficult this will be to Lars’s practice deviated from the ASRA guidelines so this line of argument may be difficult, depending on where he is practicing Lars could bring evidence to persuade the decision-maker that in the case of this particular patient or in this particular hospital, it was reasonable to deviate from the guidelines For example, Lars made a record of the consent That record may be helpful in defending his practice if it records that he documented the possibility of complications and the benefits of undertaking the procedure this way, particularly if he noted this was outside the guidelines but had good reason for doing so For example, “Discussed the increased risk of nerve damage when the block was done under general anesthetic The patient wants a block but would prefer it be done under general anesthetic, and understands the increased risk involved.” Alternatively, an anesthetist might be able to bring evidence that the hospital he was practicing in did not provide the equipment or training to enable her or him to follow the guideline As is apparent from this discussion, it will depend on the guidelines and on the evidence that you can bring to prove your practice outside them was still a reasonable standard of care Documentation of a considered decision is very helpful Where possible however, it is safer to practice within some well-recognized guidelines in the area, e.g., ASRA for regional anesthesia Rather than having to provide evidence as to why you practiced outside the guidelines, you can instead use the guidelines as evidence that your care met the standard expected at law The Emotional Toll of a Claim The stress and anger that Lars experienced after being served with a claim for malpractice is a common experience In the United States, negative emotional reaction to being sued has even been named: Medical Malpractice Stress Syndrome (MMSS) [10, 11] Lawyers are fond of telling their clients to try and be objective and retain some emotional distance from their case While emotional detachment is often considered a key attribute of being a professional, and likely something you strive for in practice, it is probably unattainable when you are at the subject of the claim Discussions with your lawyer will help to educate you about the legal process, the evidence that is required, and your prospects of a successful defence This in itself can help reduce stress, as it increases a sense of control and reduces panic However, simply putting aside the emotional response or striving to be detached is unlikely to be successful and may be harmful The literature on MMSS has some useful practical suggestions for managing stress and seeking support, including surrounding yourself with trusted advisers, maintaining other interests (such as sport and hobbies) and taking an active role in your defence www.ajlobby.com 488 B Toy-Cronin and K Byrne Conclusion A claim of malpractice is just that, a claim Even if you practice without breaching your duty of care towards your patients, you are not immune from a claim being made against you Several things can help protect you from a claim: Familiarize yourself with the law in your country about what constitutes valid consent Your insurer will probably publish this information Engage with patients during consent and listen carefully to what they say Warn the patient of the risks of nerve injury and, particularly in obstetric anesthesia, incomplete blocks These are the most common sources of claims Be courteous and respectful Patients are less likely to make claims if they have been treated with dignity If you are the subject of a claim, then your lawyer will be interested in evidence Lawyers need to be able to present evidence that counters the claimant’s version of events For example, evidence of consent, evidence of thoughtful deviation from guidelines, evidence of handover of care to another practitioner It is for this reason that doctors are frequently admonished to keep careful records They are evidence that can clear up misunderstandings and end a claim Therefore, Keep thorough records If you are notified of a claim, then keep these points in mind: Do not alter records Call your insurer Choose a lawyer (this may have to be done in consultation with your insurer): (a) Make sure the lawyer has expertise in the area (b) If there is a co-accused (such as the hospital or another practitioner), consider whether you need a separate lawyer, e.g., if your defence is that the other practitioner was at fault, not you, you need a separate lawyer Be honest with your lawyer and provide him or her with accurate information, even if it does not show you in the best light Seek support from your family, friends, and colleagues References Cook TM, Bland L, Mihai R, Scott S. Litigation related to anaesthesia: an analysis of claims against the NHS in England 1995–2007 Anaesthesia 2009;64:706–18 Kluger MT, Townend K, Laidlaw T. Job satisfaction, stress and burnout in Australian specialist anaesthetists Anaesthesia 2003;58:339–45 Brennan TA, Sox CM, Burstin HR. Relation between negligent adverse events and the outcomes of medical-malpractice litigation N Engl J Med 1996;335:1963–7 Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, Newhouse JP, Weiler PC, Hiatt HH. Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I 1991 Qual Saf Health Care 2004;13:145–51 Macdonald R. Problems with regional anaesthesia: hazards or negligence? Br J Anaesth 1994;73:64–8 White SM, Baldwin TJ. Consent for anaesthesia Anaesthesia 2003;58:760–74 Hoffman AC, Sanbar SS. Spoliation: record retention, destruction, and alteration In: Sanbar SS, editor The medical malpractice survival handbook Philadelphia: Mosby Elsevier; 2007 p. 45–54 Bernards CM, Hadzic A, Suresh S, Neal JM. Regional anesthesia in anesthetized or heavily sedated patients Reg Anesth Pain Med 2008;33:449–60 Fearnley RA, Bell MD, Bodenham AR. Status of national guidelines in dictating individual clinical practice and defining negligence Br J Anaesth 2012;108:557–61 10 Charles SC. Coping with a medical malpractice suit West J Med 2001;174:55–8 11 Sanbar SS, Firestone MH. Medical malpractice stress syndrome In: American College of Legal Medicine, editor The medical malpractice survival handbook 1st ed Philadelphia: Mosby Elsevier; 2007 p. 9–15 www.ajlobby.com Index A Abdominal wall blocks coagulopathy, 223 complications, 219 femoral nerve block, 221 intra-abdominal structures, 220–221 local anesthetic toxicity, 221–222 morbid obesity, 222 pediatrics, 222–223 practice of, 219 practitioners, 223 pregnancy, 223 systemic absorption, 223 transversus abdominis muscle, 223 trauma, 220 Abdominal wall blood vessels, 220 Abdominal wall trauma, 220 Abdominopelvic surgery, 236 Abdominoplasty, 400, 401, 404–406 Abscess encapsulation, neural ablative procedures, 276 Accidental dural puncture, 322 Activated partial thromboplastin time (APTT), 233, 234 Acute compartment syndrome (ACS), 177, 178, 333 Acute morbidity, 48 Adamkiewicz’s artery, 232 Adjuvant epinephrine, 294 Adjuvant opioids, 294, 296 Adjuvants, 91 ADP receptor blockers, 144 Adrenaline, 228 Adverse events apnea and syncope, 266 medical intervention, 189 neurological, 268 vigilance, 280 Alfentanil, 321 Alpha-1-acid glycoprotein (AAG), 45 Alpha-adrenergic agonists, 248 Ambulatory anesthesia, 60 American Society for Aesthetic Plastic Surgery (ASAPS), 400 American Society of Anesthesiologists (ASA), 474 closed claims project, 271, 451, 476–477 Manual on Professional Liability 2010, 474 closed claims review, 328 Syllabus on Ethics, 474 American Society of Regional Anesthesia (ASRA), 10, 41, 233, 234, 240, 414 American Society of Regional Anesthesia and Pain Medicine (ASRA), 140, 332 Amyotrophic Lateral Sclerosis (ALS), 106 Anesthesia, 402–407 in abdominoplasty, 401 in face lift, 401–402, 405–407 allergic reactions, 405 deaths, 406 infusion pain pump, 405, 406 toxicity of topical anesthetics, 406 in hand surgery, 401 in liposuction, 400–401 in plastic surgery, 399–403 cardiotoxicity, 403 central neural blockade, 402 failure, 404 Horner syndrome, 403 nerve injury, 404–405 pneumothorax, 404 toxicity, 403 treatment of toxic reactions, 407 vascular complications, 403 wrong anesthetic solution, 404 Anesthesia Quality Institute (AQI), 475 Anesthesiologist, 247, 430 Anesthetic agents, 189 Anesthetic blocks, 432 Anesthetic doses for nerve block, 296 Anesthetic events, neurologic injury, 115–116 Anesthetic management, CNS infections, 160–161, 163 Anhidrosis, 116 Anterior paratracheal approach, stellate ganglion block, 262 Anterior superior alveolar nerve block, 344 Anterior superior iliac spine (ASIS), 220, 221 Anticoagulants, 18, 140, 142–144, 146, 176 apixaban, 143 aspirin, 141–143 clopidogrel, 143 dabigatran, 143 heparins, 143–144 newer, 144–145 nonaspirin NSAIDs, 142 NSAIDs, 141, 143 pharmacologic, 141 prasugrel, 143 rivaroxaban, 143 subcutaneous heparin, 143 warfarin, 142–143 Apixaban, 144, 145 ARAC See Australasian Regional Anaesthesia Collaboration (ARAC) Arachnoiditis, 229, 238–239, 271 Articaine, 341–344, 353 ASA Manual on Professional Liability (2010), 475 Aseptic meningitis, 271 © Springer International Publishing AG 2017 B.T Finucane, B.C.H Tsui (eds.), Complications of Regional Anesthesia, DOI 10.1007/978-3-319-49386-2 www.ajlobby.com 489 490 Index Aseptic technique breaks in sterile circuit, 159 catheter disconnects, 159–160 Gowns, 158 Hand Washing, 158 Masks, 158 Preparation of Injectate and Infusate, 159 Skin Disinfection, 158–159 Aspirin, 141, 142 Aspirin therapy, 19 ASRA See American Society of Regional Anesthesia (ASRA) Atropine, 436 AURORA See Australian and New Zealand Registry of Regional Anaesthesia (AURORA) Australasian regional anaesthesia collaboration data quality control methods, 422 PNB, 422, 423 postoperative neurologic symptoms, 423 project requirements, 422, 423 Australasian Regional Anaesthesia Collaboration (ARAC), 415 Australian and New Zealand Registry of Regional Anaesthesia (AURORA), 419 Australian Incident Monitoring Study (AIMS), 328 Autoimmune inflammatory nerve diseases, 119 Autoimmune nerve, 114 Autonomic nervous system studies, 118 Axillary brachial plexus block (AXB), 193 Axonotmesis, 124–126 B Babinski signs, 116 Backache, 250, 251 Bainbridge reflex, 248 Barrel syndrome, 115 Behavioral factors and complications fatigue, 24 hazard of boredom, 24 physical and mental factors, 24 sleep deprivation, 23 work environment, 24 Benzodiazepines, 19, 321 lorazepam, 289 midazolam, 289 opioids, 289 remifentanil, 289 Bezold–Jarisch reflex, 248, 455 Bier block, “Black box” system, 437 Bleeding complications, 140–141 Blood patch therapy, 331 Blood serology, 114 BMI, 319–323 Boluses, 254 Brachial plexus anesthesia, 10 Brachial plexus block, 288, 292 Brain and spinal cord, 116 Brainstem anesthesia, 371 Bupivacaine, 114, 247, 249–253, 330, 332, 335, 343, 400, 402, 403, 406, 407, 436, 437 C Caffeine, 254, 331 CAIT See Compressed air injection technique (CAIT) Canadian Medical Protective Association (CMPA), 429–431, 433, 434 Cancer recurrence postsurgery, 60 Cannula-over-needle design, 169 Capnography, 27 Cardiac arrest, 249, 313, 436 Cardiac dysrhythmias, 17 Cardiac toxicity, 47 Cardiovascular system, 17 Catheter, 167–179 Catheter migration, 322 Catheter site infections, 324 Catheters, 168, 170 Cauda equina, 231, 238, 239 Cauda equina lesion, 311 Cauda equina syndrome, 251, 253, 255, 432 Celiac plexus block, 266–267 Central nervous system (CNS) infections, 150–160 anesthetic management, 160–161 anesthetic management, 163 aseptic technique (see Aseptic technique) epidural abscess (see Epidural abscess) infectious complications of peripheral regional techniques, 161–163 meningitis (see Meningitis) neuraxial blockade (see Neuraxial blockade) neuraxial infectious complications, 161 neuraxial techniques, 149 peripheral infectious complications, 163 risk factors, 149 Central nervous system toxicity, 47 Central neural blockade (CNB) ambulatory anesthesia, 60 cancer recurrence postsurgery, 60 cochrane reviews, 57 epidural analgesia, 57 hip/knee surgery, 58–59 MASTER trial, 57 meta-analysis, 57 myocardial infarction, 57 neuraxial analgesia and anesthesia, 58 perioperative care, 58 perioperative myocardial infarction and renal failure, 57 PNB, 60–61 POCD, 59 POD, 59–60 postoperative outcome, 57 respiratory failure, 57 vascular surgery, 57 Central neuraxial block, 229, 230, 233, 235, 239, 240 denominator, 448 NAP3, 448 numerator, 448 RCTs, 448 spinal and epidural analgesia, 293 strengths and weaknesses, 448 Cerebrospinal fluid (CSF), 115, 323 Cervical sympathetic trunk (CST), 262, 265 Chemical neurotoxicity, 190, 191 Chlorhexidine, 236, 239, 246 Chondrotoxicity, 385, 386, 390–392 Chronic adhesive arachnoiditis, 310 Chronic pain management, 463–464 2004 analysis, 464 Chronic pain therapy, 261–268, 271–279 epidural blockade (see Epidural blockade) facet joint radiofrequency denervation, 270–271 intravenous regional sympathetic block, 266 www.ajlobby.com Index 491 management, 261 neural ablative procedures (see Neural ablative procedures) SCS (see Spinal cord stimulation (SCS)) somatic nerve blocks, 270 stellate ganglion block (see Stellate ganglion block) sympathetic blockade techniques, 261 thoracic and lumbar sympathetic blockade, 265–266 visceral nerve blocks (see Visceral nerve blocks) Chronic salicylate therapy, 142 Chylothorax, 268 Claim, 483–488 Clinical practice guidelines (CPGs), 34 Clinical registry advantages and limitations, 416–417 definition, 415 examples, 417 managing, 417 RCT, 416 Clopidogrel, 235 Closed Claims Project, 452, 463, 466, 469 Closed-mouth mandibular block, 348 Clotting mechanisms, 18 Coagulation agents effecting, 145–146 warfarin, 142, 143 Coagulation abnormality, 140 Coagulopathy, 139, 223, 233 Cocaine, 42 Cognitive dysfunction, 57 POCD, 59 Combined spinal-epidural (CSE) technique, 22, 23, 228, 230, 231, 238, 241, 323 complications, 22 double-lumen needles, 22 nerve blockade, 22, 23 Compartment syndrome, 333 Complex regional pain syndrome (CRPS), 466–467 Complication anticipation, 18–19 cardiovascular system, 17 clinical assessment, 17 gastrointestinal tract, 17, 18 hematologic (see Hematologic system) nervous system, 16 preoperative assessment, 16 respiratory system, 16 Compound muscle action potential (CMAP), 119 Compressed air injection technique (CAIT), 93 Computed tomography (CT), 127–128 Computer-Controlled Local Anesthetic Delivery (C-CLAD), 355 Connective tissue disease, 114 Continuous catheter techniques, 390 Continuous peripheral nerve block (CPNB) accidental vascular puncture and hematoma formation, 176 and acute compartment syndrome, 177–178 advantages and disadvantages, 179 after ambulatory surgery, 167 catheter dislocation, 173 catheter/needle assemblies, 179 catheterization kits, 168–169 catheters, 168 complications, 172–177 electrical nerve stimulation, 169–171 falls, 178 inaccurate catheter tip placement, 172–173 infectious complications, 173–174 local anesthetic toxicity, 176–177 needle choice, 168 neurological complications, 175 opioid analgesics, 167 paresthesias and tactile feedback, 169 patient preparation, 167–168 perineural infusions, 178–179 phrenic nerve palsy, 178 supraclavicular brachial plexus, 167 ultrasonographic catheter, 172 ultrasound guidance, 171–172 wound/intra-articular local anesthetic infusion, 167 Conventional angiography, 132, 133 Cord damage, 311 Crystalloid preload, 248 Cushingoid side effects, 272 CUSUM analysis, 229 Cutaneous atrophy, 116 Cyclooxygenase-1 (COX-1), 141 D Dabigatran, 145, 235 Danish Patient Insurance Association’s (PIA), 442 Deep venous thrombosis (DVT), 58 Defensive medicine, 433 Denervation, 124 Dental injury claims, 452 Dental local anesthesia, 343–344, 350–354 complications allergy to local anesthesia, 354 needle breakage, 350–354 paresthesia, 352–353 self-inflicted soft tissue injury, 354 toxicity (overdose), 354 transient facial nerve paralysis, 353–354 formulations, 343–344 articaine, 343 bupivacaine, 343 lidocaine, 343–344 mepivacaine, 344 prilocaine, 344 mandibular injection techniques, 346–350 maxillary injection techniques, 344–346 supplemental injection techniques, 350 Dermabond®, 173 Dexamethasone, 272 Dexmedetomidine, 289, 321 Diarrhea, 267 Disabilities and legal outcome, 430 Discharge readiness, 61 Disco dancing, 117 Dorsal rhizotomy, 270 Dorsal root entry zone (DREZ), 270 Dorso-lumbar nerve (T12-L1), 385 Dose recommendations, 50 Double-crush syndrome, 88, 103 Double-lumen needles, 22 Dural puncture, 153, 154 E Electrocardiogram (ECG), 267 Electrodiagnostic studies, 118 anesthesia-induced injuries, 118 autoimmune inflammatory nerve diseases, 119 EMG (see Electromyography (EMG)) www.ajlobby.com 492 Index Electrodiagnostic studies (cont.) NCS (see Nerve conduction studies (NCS)) pathogenic processes, 119 QSART, 118 TST, 118 Electromyography (EMG) axonotmesis, 124, 125 collateral sprouting and neural regeneration, 125 concentric and monopolar, 123 decreased recruitment, 124 denervation, 124, 126 electrical activity, 123 electrophysiologic changes, 125 fibrillation potentials, 123, 125 increased MUP duration and amplitude, 126 limitations and benefits, 127 motor axonal loss, 125 MUPs, 123, 124 muscle fibers, 125 neuromuscular disorders, 124 neuropraxia, 124 neurotmesis, 124 practical approach, 127 reinnervation proceeds, 125, 126 Seddon classification, 124 spontaneous activity, 123 stable MUP, 126 types of neuronal injury, 124, 125 unstable MUP, 126 Emergency department, regional anesthesia practice, 359–360 alcohol withdrawal treatment options, 366 avoiding local anesthetic toxicity, 363 avoiding premature resolution of block, 363 avoiding prolonged block, 363 documentation, 362 fracture hematoma blocks, 360–361 intoxicated patient, 364–366 local anesthetic selection, 362–363 opioid withdrawal treatment options, 366 patient in acute withdrawal, 366 preexisting neurologic injury, 364 promoting safety and efficiency, 361–362 reducing delay, 364 strategies to promote timely utilization, 364 sympathomimetic treatment options, 366 unique patient considerations, 364 Endoscopic ultrasound-guided (EUS) injection, 267 Enhanced recovery after surgery (ERAS) programs, 228 Ephedrine, 248, 436 Epidemiological triangle, 68 anatomy and physiology, 87, 88 host/biological factors, 87 neurological injury, 68 neuropathy, 88, 89 surgical factors, 88 Epidural abscess, 442 after epidural anesthesia, 155 after neuraxial anesthesia, 150–153 diagnosis, 150 epidemiology, 150 identified organisms, 150 spinal procedures, 150 steroid administration, 150 Epidural anesthesia, 9, 10, 36, 155, 229–231, 234, 235, 239, 293–294, 442, 443 Epidural blockade, 272–273, 431–432 advantages, 271 American Society of Anesthesiologists Closed Claims Study, 271 analgesia, 227 antiplatelet agents, 235 arachnoiditis and neurotoxicity, 238–239 cervical, thoracic, lumbar/sacral regions, 271 chronic pain, 241 coincidental causes, neurologic injury, 229–230 complications and side effects, 273 diagnosis and treatment, 233 dural puncture, 272 ERAS, 228 etiology, 232, 239 incidence, 232–233 infection, 272 intrathecal opioid and paravertebral block, 228 intravertebral abscess and meningitis, 235–236 intravertebral hematoma, 232–233 laboratory values, 233 LAST, 239–240 MASTER trial, 228 mechanical and traumatic complications, 271 neurologic injury, 271–272 neurological complications, 230–231 neurotoxicity, 271 obstetric, 240 oral anticoagulants, 235 patient populations, 228 pediatric, 240 perioperative setting, 228 practice, 241 prevention, 233, 236 RCT, 227 retrospective analysis, 228 risks, 229 safe and effective, 228 spinal cord and nerve root trauma, 237–238 spinal cord ischemia and infarction, 236–237 systemic opioid-based techniques, 228 systemic side effects epidural opioid, 273 steroids, 272–273 training, 228–229 transforminal approach, 271 unfractionated heparin and LMWH, 233–235 wrong drug and wrong route errors, 239 Epidural blood patch (EBP), 254, 255 Epidural infusion analgesia (EIA), 328, 329 Epidural local anesthetics, 449 Epidural opioid, 273 Epidural or intrathecal space infection, 276 Epidural saline or colloid, 254 Epidural steroid injections, 271–273 Epidural stimulation test, 331 Epidural Tuohy needle, 232 Epinephrine, 252, 253, 293, 296, 362, 374, 377, 382, 383, 386, 390, 391, 393, 394, 399–402, 404, 405, 407, 455, 457 Erythrocytes, 45 Esophagus, 263 European Society of Regional Anesthesia and Pain Therapy (ESRA), 140 Eutectic mixture of lidocaine (EMLA), 174 Expiratory reserve volume (ERV), 320 Exteriorized catheter, 276 www.ajlobby.com Index 493 F Face lift, anesthesia in, 405, 406 complications, 405 allergic reactions, 405 deaths, 406 infusion pain pump, 405, 406 toxicity of topical anesthetics, 406 Facet joint block, 270 Facet joint radiofrequency denervation, 270, 271 Falls, 178 Femoral nerve block (FNB), 194, 221, 383 Fentanyl, 321 Fibrillation potentials, 123, 125 Finnish Patient Insurance Centre (PIC), 441, 442 Fisher’s exact test, 454 Flexometallic catheters, 174 Fluoroscopically guided percutaneous radiofrequency denervation, 271 Fondaparinux, 235 French-Language Society of Pediatric Anesthesiologists (ADARPEF), 327–329 Functional residual capacity (FRC), 320 F-wave response, 120 G Ganglion impar injection, 269 Gastrointestinal tract, 17–18 General anesthesia intraoperative epidural anesthesia, 57 neuraxial anesthesia, 58 neuraxial-general anesthesia, 59 neuraxial-general group, 59 PNB, 60 POD and POCD, 60 and systemic analgesia, 58 Glenohumeral chondrolysis, 392 Goldman index, 17 Gow-Gates Mandibular Nerve Block, 348 Gradient recalled echo (GRE), 130 Greater palatine nerve block, 345 Guanethidine, 266 Guillain–Barré syndrome autonomic dysfunction, 108 regional anesthesia, 108 treatment, 108 H Hand surgery, anesthesia in, 401 Harvard Medical Practice Study, 452 Health Services Research Centre (HSRC), 448 Hematologic system aspirin therapy, 19 benzodiazepines, 19 clotting mechanisms, 18 diabetes, 19 histaminoid reactions, 18 medications, 19 methemoglobinemia, 18 muscle disease, 18, 19 nifedipine, 19 pseudocholinesterase dysfunction, 18 quinidine and disopyramide, 19 verapamil, 19 Hematoma blocks, 360–361 Hematomas, 263 Hemorrhage, 370 Heparins, 143, 144 Hepatic metabolism, 46 Herpes simplex virus type-2 (HSV-2), 156 High Block/Total Spinal Block, 456 High-volume local anesthetic infiltration (HVLIA), 228, 381–382 Hilton’s law, 385 Hip arthroplasty, 387 Hip fracture surgery, 448–449 Hip Joint, innervation of, 385 Hip/knee surgery, CNB acute confusional state, 58 cochrane review, 58 complications, 59 DVT and intraoperative blood loss, 58 global public health issue, 58 logistic regression analysis, 59 lower limb arthroplasty surgery, 58 meta-analysis, 58 National Hip Fracture Database (UK), 59 observational study, 59 orthopedic population, 58 outcome, 59 population-based databases, 59 regional anesthesia, 58 THA and TKA, 59 total knee arthroplasty (TKA), 58 Histaminoid, 18 Horner syndrome, 262, 264, 403 HSRC See Health Services Research Centre (HSRC) Human immunodeficiency virus (HIV), 156–157 Human serum albumin (HSA), 45 Hyaluronidase, 374, 377 Hyperbaric local anesthetics, 255 Hyperbaric tetracaine, 295 Hyperechoic injectate, 172 Hyperhidrosis, 116 Hypotension, 304, 305, 322, 323 Hypovolemia, 248 I Iatrogenically induced steroid myopathy, 273 ILE See Intralipid emulsion (ILE) Implantable catheters and drug delivery system, 275–276 Implantable drug delivery systems (IDDS), 468 Incisive (Mental) nerve block, 349–350 Infection, 149, 172–174, 176, 179, 229, 235, 236, 240, 241 antibiotic therapy, 309 CNS (see Central nervous system (CNS) infections) neuraxial blockade, 309 occlusive dressings, 309 skin disinfectant, 309 Inferior alveolar nerve block, 346–348 Infiltration anesthesia, 382 Inflammatory mass, 279 Infraclavicular, 193 Infraclavicular brachial plexus block (ICB), 193 Infra-gluteal technique, 324 Injection pressure monitoring BSmart™ device, 93 CAIT, 93 OP and IP, 93 syringe feel, 93 Injection, equipment and technique, 386 Injuries related to implantable devices, 469 www.ajlobby.com 494 Index Injury and liability cervical procedures for chronic pain, 466–468 implantable devices for chronic pain, 468–469 Interference pattern, 123, 124 International Registry of Regional Anesthesia (IRORA), 419 International Study of Postoperative Cognitive Dysfunction (ISPOCD), 60 Interscalene, 192–193 Interscalene block, 323 Interscalene brachial plexus block (ISB), 192, 193 Interspinous space, 229 Intra-abdominal structures, 220, 221 Intralipid emulsion (ILE), 41, 48, 49 Intralipid®, 240 Intraneural injection, 190, 192, 195 nerve stimulation, 91 paresthesia, 92 ultrasound guidance, 91 Intraosseous anesthesia, 350 Intraperitoneal needle tip placement, 220 Intraspinal drug delivery systems, 276 Intravenous lipid emulsion (ILE), 332 Intravenous regional anesthesia (IVRA), 8, 43, 195, 404 Intravenous regional sympathetic block agents, 266 drug effects, 266 guanethidine, 266 in upper limb, 266 Intravertebral abscess, 235, 236 Intravertebral hematoma, 232 IRORA See International Registry of Regional Anesthesia (IRORA) Ischia’s transaortic approach, 268 IVRA See Intravenous regional anesthesia (IVRA) K Ketamine, 288–290, 296, 321 Ketorolac, 382, 383, 386, 390, 394 Knee analgesia, 382 Knee Joint, innervation of, 385 L Labor and delivery, 303–313 hypotension, 304, 305 infectious complication (see Infection) local anesthetic toxicity epidural blockade, 305 fetal bradycardia, 306 lipid, 306 paracervical blocks, 306 systemic toxicity, 305 test dosing, 305 neuraxial anesthesia claims, 304 obstetric patient (see Neurological dysfunction) pudendal nerve blockade, 306, 307 regional anesthesia hypotension, 303 neurological dysfunction, 304 Laser in situ keratomileusis (LASIK), 371 LAST See Local anesthetic systemic toxicity (LAST) Levobupivacaine/Bupivacaine, 222, 394 Levonordefrin, 343, 344 Lidocaine, 42, 114, 228, 251, 252, 341, 343–344, 353, 354, 356, 360–363, 374–377, 394, 399–407, 435, 437 Lipid rescue therapy, 322 Liposuction, 400–401 Litigation, 485 Liver hematoma, 221 Local anaesthetic systemic toxicity (LAST), 424, 425 Local anesthetic, 167–175, 177–179 Local anesthetic injection, 446 Local anesthetic systemic toxicity (LAST), 42, 43, 50, 51, 176, 177, 192, 193, 195, 196, 240, 328, 332–334, 414, 442, 444, 457–458 abdominal wall blocks, 51 absorption rate, 45 action mechanism, 44 ASRA, 41, 46 cardiac resuscitation, 49 cardiotoxicity, 47 CNS, 47 distribution, 45 dose recommendations, 50 dosing, 51 drug ionization, 43 hepatic metabolism, 46 history bupivacaine, 42 cocaine, 42 IVRA, 43 lidocaine, 42 ILE, 48, 49 incidence, 42 intravenous lidocaine infusion, 52 medical management, 49 myotoxicity, 52 neurologic toxicity, 46 onset of action, 43 pediatric blocks and dosing, 50 pharmacokinetic considerations, 44, 45 pharmacokinetic parameters, 46 physicochemical properties, 44 plasma protein binding, 45 PNB, 42 potency, 44 prevention ASRA guidelines, 50 dose usage, 50 high blood levels, 50 oxygen therapy, 50 ultrasound guidance, 51 renal excretion, 46 structure and properties, 43 treatment, 48 ultrasound guidance, 41 Local anesthetics, 4–6 clearance, 291 clinical implications, 291–292 distribution, 291 general considerations, 290–292 history cocaine, 4, erythroxyline, etherization, etidocaine and bupivacaine, lidocaine, procaine, ropivacaine, systemic toxicity, 5, xylocaine, www.ajlobby.com Index 495 systemic absorption, 290 toxicity, 192, 221, 222, 240 Local infiltration analgesia (LIA) anatomical consideration, 385 arthroplasties, 384–385 arthroscopy surgeries, 387–389 composition, 386 impact on wound healing/revision surgery, 394 local institutional experience, 390 non-analgesia benefits, 387–390 in total hip arthroplasty, 386, 388–389 in total knee arthroplasty, 383, 384, 386–389 safety concerns, 385 Localized infection, neural ablative procedures, 276 Lorazepam, 289 Loss of hair, 116 Low-dose spinal anesthesia, 247 Lower extremity block procedures femoral, 194 lumbar plexus/psoas compartment, 193–194 popliteal sciatic, 195 proximal sciatic, 194 saphenous (adductor canal), 194 Lower motor neuron (LMN), 106 Low-molecular-weight heparin (LMWH), 176, 232–235, 250 Lumbar chemical sympathectomy, 266 Lumbar epidural block, 328 Lumbar plexus/psoas compartment, 193–194 Lumbar sympathetic blockade, 265 and Thoracic (see Thoracic and Lumbar Sympathetic Blockade) Lyme disease, 114 M Magnetic resonance imaging (MRI), 128–132, 231, 232, 235–238 neurologic injury indications, 130–132 limitations, 128–130 technology, 128, 129 Magnetic resonance neurography (MRN), 131–132 Maintenance-related claims, 469 Malpractice, 483–488 Malpractice insurance, 485 Mandibular injection techniques, 346–350 Mandibular technique, 342 Mann–Whitney U Test, 454 Manual muscle testing, 117 MASTER trial, 227, 228 Maxillary (V2) nerve block, 345–346 Maxillary injection techniques, 344–346 Medical legal actions, cost, 433 Medical Malpractice Stress Syndrome (MMSS), 487 MEDLINE©, 68, 287 Meningitis, 236, 239, 240 after dural puncture, 153–154 after neuraxial anesthesia, 150–153 after spinal and epidural anesthesia, 154 diagnosis, 150 epidemiology, 150 positive/negative CSF cultures, 150 spinal anesthesia, 150 Mental status/cranial nerves, neurologic injury, 116 Mepivacaine, 344 Metabolic syndrome, 319, 320 Methicillin-sensitive Staphylococcus aureus (MSSA) infections, 272 Methoxamine and phenylephrine, 248 Midazolam, 289, 321 Middle superior alveolar nerve block, 344–345 Monitoring devices BP measurement, 28 capnography, 27 cardiac rate and rhythm, 27 components, 29 instrumental monitors, 27 oscillometric measurement, 28 plethysmography, 28 pulse oximeters, 27 systemic arterial pressure, 28 thermometrography, 29 Morbid obesity, 222, 320 Morbidity, 448, 449 Motor examination, neurologic injury, 117 Motor nerve conductions, 119, 120 Motor paresis analgesia, 274 central neurolysis, 274–275 CSF, 275 dorsal root, 275 epidural neurolysis, 275 lesion target, 275 peripheral neurolysis, 275 preexisting limb weakness, 274 strict selection criteria, 275 subarachnoid neurolysis, 275 subarachnoid phenol injection, 275 suprascapular block, 274 Motor unit potentials (MUPs), 123, 124 “Moving needle” technique, 386 Multicentre Australian Study of Epidural Anesthesia (MASTER trial), 57 Multiple sclerosis, 114 cardiovascular autonomic dysfunction, 106 characterization, 104 diagnosis, 105 epidural anesthesia, 105 perioperative relapse, 106 regional anesthesia, 106 spinal anesthesia, 105 symptoms, 105 treatments, 105 Multiple-injection paravertebral nerve block (MPVB), 403 Muscle atrophy, 116 Muscle diseases, 114 Muscle fibers, 125 Muscle stretch reflexes, 118 Musculoskeletal disturbances, 251 Myasthenia gravis, 114 anesthetic consideration, 110 regional anesthesia, 110 treatment, 110 Mycobacterium organisms, 276 Myocardial infarction (MI), 57 Myopathies, 114 Myotonic dystrophy pregnant patients, 109 regional anesthesia, 109 treatment, 109 type and 2, 109 N Narcotic analgesics, 254 Nasopalatine nerve block, 345 www.ajlobby.com 496 Index National audit project (NAP), 448 National Audit Project of the Royal College of Anesthetists (UK) (NAP 3), 58 National Hip Fracture Database (UK), 59 National Institute of Academic Anesthesia (NIAA), 448 National Institute of Clinical Excellence (NICE), 487 National Patient Safety Agency (NPSA), 446 National Reporting and Learning System (NRLS), 446 Nausea and vomiting, 249 Needle trauma, 89, 190 Nerve block, 425, 426 Nerve conduction studies (NCS), 118 and EMG (see Electromyography (EMG)) late responses, 119–121 limitations, 122–123 motor, 119, 120 and muscles, 127 NCS (see Nerve conduction studies (NCS)) sensory, 121 sensory nerve conduction, 121–122 Nerve injury, 392–393 Nerve injury claims, 464 Nerve localization technique, 422 Nerve plexuses, 116 Nerve roots, 116 Nerve stimulation, 10 animal studies, 92 hyperglycemia, 92 intra- and extraneural needle placement, 92 Nervous system, 16 Neural ablative procedures, 274–275, 277, 278 device-related complications, 277–279 drug-related complications endocrine side effects, 277 implantable catheters, 277 intolerable paresthesia and motor paresis, 277 local anesthetic-induced CNS toxicity, 277 long-term high-dose local anesthetic administration, 277 long-term spinal opioid administration, 277 opioid and bupivacaine, 277, 278 postural hypotension, 277 randomized controlled trial, 277 respiratory depression, 277 systemic opioid to spinal opioid, 277 implantable catheters and drug delivery system, 275–276 infection, 276–277 inflammatory mass, 279 miscellaneous, 279 neurologic complications chemical neurolysis, 274 diagnostic local anesthetic block, 274 loss of bladder and bowel control, 275 motor paresis, 274–275 postblock pain, 275 neurological injury, 276 neurolysis of peripheral nerves, 274 neuropathic effects of neurolytic agents, 274 Neural blockade and surgery, 24–27 Neural blockades complications airway obstruction, 29 caudal epidural blockade, 31 cervical plexus blockade, 31 epidural blockade, 31 epinephrine complications, 30 infraclavicular brachial plexus blockade, 31 intercostal nerve blockade, 32 local anesthetic focal complications, 30 risks, 30 subarachnoid block, 32 supraclavicular brachial plexus, 31 thoracic paravertebral anesthesia, 32 upper and lower limbs, 30 Neuraxial anesthesia, 150–152, 360 combined spinal-epidural, 323 epidural, 322–323 meningitis and epidural abscess diagnosis and treatment, 150, 152 echo, 152 epidemiologic studies, 152 identification, 152 infectious complications, regional anesthesia, 150, 151 neuraxial infection, 152 obstetrical patient group, 152 perioperative antithrombotic therapy, 150 S aureus, 152 symptomatic epidural abscess, 150 symptoms, 152 time interval, 152 spinal anesthesia, 323 Neuraxial blockade, 139, 153–157, 231, 233, 234, 442, 443 in febrile/infected patient epidural abscess after epidural anesthesia, 155 HIV, 156–157 HSV-2, 156 meningitis after dural puncture, 153–154 meningitis after spinal and epidural anesthesia, 154–155 Parturient, 155–156 in immunocompromised patient, 157–158 Neuraxial cardiac arrest, 452, 455–456 Neuraxial hematoma, 459, 461 Neuraxial infection, 272 Neuraxial morbidity, 444 Neuraxial opioid analgesia, 115 Neuraxis, 459–460 Neurologic complications, PNB, 70–74, 84, 85, 89–93 animal studies dog, 70, 72 pig, 70–73 rabbit, 70, 73, 74 rat, 70, 71, 73, 74 ASRA, 86 case reports, 82–83, 86 causative agent factors, 89 chemical agents adjuvants, 91 injection pressure monitor, 93 intraneural injection, 91, 92 nerve stimulation, 92 neurotoxicity, 90, 91 classification, 94 closed claims analyses, 69, 78, 80 EMG, 95 epidemiological principles, 68 evidence evaluation, 69 anatomical factors, 84 environmental influences, 85 incidence, 85 needle trauma, 84 neurotoxicity, 84 ultrasound, 85 general anesthesia, 86 human and animal studies, 68 www.ajlobby.com Index human studies assessment, 75–77 injury and clinical symptoms, 95 mechanical agents needle trauma, 89 pressure injury, 90 outcomes, identification, 95 procedure-induced paresthesia, 69, 86 prospective study, 78–81 RCTs, 68 retrospective review, 69, 79–81 search strategy, 68 symptoms, 95 ultrasound (see Ultrasound guidance) ultrasound (US), 67 Neurologic deficit, 194 Neurologic disease, 104–106 cardiovascular effects, 104 double crush, 103 myocardial dysfunction and arrhythmias, 104 pharyngeal muscles dysfunction, 104 regional anesthesia, 104–106 regional anesthetic, 103 respiratory complication, 104 Neurologic injury, 119–127, 175, 229–232 anesthetic events, 115–116 blood tests, 114 complications of regional anesthesia, 134–135 conventional angiography, 132–133 coordination/gait, 118 CT, 127–128 development of neurologic dysfunction, 116 electrodiagnostic evaluation, 118–119 evaluation, 113 general examination, 116 identification, 114 integration, 135–136 mental status/cranial nerves, 116 motor examination, 117–118 MRI, 128–131 MRN, 131–132 nerve conductions (see Nerve conductions) neurologic examination, 116 noninvasive angiography, 133 physical examination, 116 plain films/conventional radiography, 127 preexisting conditions, 114 reflexes, 118 regional anesthesia, 113 sensory examination, 118 smoking gun, 113 surgical events, 114–115 ultrasound, 134 Neurologic and neurovascular sequelae, 268 Neurological dysfunction, 307–309, 311, 312 cardiac arrest, 313 cauda equina lesion, 311 chronic adhesive arachnoiditis, 310 cord damage, 311 extensive block, 312 inadequate block epidural, 312 spinal anesthesia, 312 vaginal delivery, 311 infection, 309 obstetric palsies, 307 postdural puncture headache, 310, 311 497 respiratory depression, 313 spinal–epidural hematoma antithrombotic agents, 309 antithrombotic therapy, 307 grade larynx, 309 prophylactic dose, 308 regional anesthesia/analgesia, 308 transient neurological symptoms, 311 Neurolytic agents, neuropathic effects, 274 Neurolytic lumbar sympathetic block, 432 Neuromuscular disorders, 124 Neuropathic effects of neurolytic agents, 274 Neuropathy, 88–89 Neuropraxia, 124, 125, 240 Neurotmesis, 124, 126 Neurotoxicity, 90, 91 NHS England, 446 NIAA See National Institute of Academic Anesthesia (NIAA) Nifedipine, 19 Nociception, 118 “No-fault” compensation schemes, 486 Nonaspirin NSAIDs, 142 Noniatrogenic causes, 229 Noninvasive angiography, 133 Nonsteroidal anti-inflammatory drugs (NSAIDs), 141, 235 Nordic countries, 441 Novocain, 341, 343 NPSA See National Patient Safety Agency (NPSA) O Obesity, 319–322, 431, 434 and BMI, 320 cardiovascular considerations, 320 classification, 320 pharmacology effect of obesity, 320–322 lipid rescue therapy, 322 local anesthetics, 321–322 sedation, 321 respiratory considerations, 320 Obesity hypoventilation syndrome (OHS), 320 Obstetric anesthesia, 430, 432–433, 452 Obstructive sleep apnea (OSA), 228, 319, 321 Ophthalmic regional anesthesia, 369–370 allergy, 374 alternative methods, 375 anesthesia for cataract surgery, 375–376 anticoagulants and antiplatelet therapy, 374–375 brainstem anesthesia, 371 complications, 370 effects on ocular circulation, 374 hemorrhage, 370 optic nerve damage, 374 pupillary anomalies, 374 seventh nerve block complications, 374 strabismus, 372–373 sub-tenon’s anesthesia, 376–377 therapeutic misadventures, 374 Opioid, 289, 296, 319, 321 Optic nerve damage, 374 Oscillometric measurement, 28 Outcome studies advantages and disadvantages, 56 definition, 55 measurements, 55 www.ajlobby.com 498 Index Outcome studies (cont.) medical decisions, 55 meta-analyses, 56 perioperative management of patients, 57 randomized controlled trial, 56 RCTs, 56 regional anesthesia, 55, 56 retrospective database research, 56, 57 Oxford Centre for Evidence-Based Medicine levels, 69 P Pain, chronic See Chronic pain therapy Paravertebral nerve bock (PVD), 402 Paresthesia, 169, 175, 250, 352, 353 Patient assessment See Preanesthetic examination Patient Injuries Act, 441 Patient morbidity, 445 Patient-controlled analgesia (PCA), 228, 383 Pectoral nerve (PEC) blocks, 168 Pediatric anesthesia, 328 Pediatric blocks and dosing, 50 “Pediatric common sense” safety considerations, 334–336 Pediatric regional anesthesia, 327–330 assessment of catheter tip placement, 331–332 compartment syndrome, 333 dural puncture, 331 epidural hematoma, 331 infection, 332–333 LAST, 332 neural injury, 330–333 ultrasound guidance on complications, 333–334 Pediatric regional anesthesia network (PRAN), 329 Pediatrics, 222 Pelvic visceral nerve blocks, 269, 270 Peribulbar block, 371, 374, 375 Perinatal asphyxia, 433 Perineural catheter, 171, 173 Periodontal ligament (PDL) injection, 342, 350 Perioperative antithrombotic therapy, 150 Peripheral nerve blockade (PNB), 9, 42, 167, 170, 171, 175, 176, 178, 292–293, 414, 415, 418, 419, 422, 423, 425, 458–459 and ambulatory anesthesia, 60 brachial plexus, 323–324 in children, 328–330, 333, 336 lower extremity blocks, 324 transverse abdominis plane block, 324 Peripheral nerve catheter, 175 Peripheral nerve entrapments, 114 Peripheral nerve injury chemical neurotoxicity, 190–191 diagnosis and management, 191 direct trauma, 190 disruption of perineurium, 191 incidence, 191 nerve entrapment syndromes, 191 prevention, 191–192 vasoconstrictor effect, 191 Peripheral neuropathies, 108 Pharmacologic anticoagulation, 141 Pharynx, 263 Phenol-induced cardiotoxicity, 268 Phentolamine mesylate, 355–356 Phenylephrine, 248, 252, 305 Phosphodiesterase inhibitors, 235 Physician–patient relationship, 473, 474 Plain films/conventional radiography, 127 Plasma protein binding, 45–46 Plasma ropivacaine concentrations, 222 Plastic surgery, 402–405 anesthesia, 399–403 cardiotoxicity, 403 central neural blockade, 402 failure, 404 Horner syndrome, 403 nerve injury, 404–405 pneumothorax, 404 toxicity, 403 vascular complications, 403 wrong anesthetic solution, 404 Plavix, 459 Plethysmography, 28 Plexus block (PNB), 228 PNB See Peripheral nerve blockade (PNB) Pneumothorax, 263, 268, 402, 404, 405, 432, 433, 463, 464 PNI See Postoperative nerve injury (PNI) Polyneuropathies, 114 Polyurethane catheter, 175 Popliteal sciatic, 195 Postanesthesia care unit (PACU), 61 Postblock pain, 275 Postdural puncture headache (PDPH), 245, 253–255, 279, 310, 311, 322, 328, 331, 431–433 definition, 253 EBP, 254, 255 etiology, 253, 254 treatment, 254 Posterior superior alveolar (PSA) nerve block, 345 Postoperative cognitive dysfunction (POCD), 59, 288, 292 Postoperative complications bladder distention, 33 cardiovascular system, 30 central nervous system, 32 endocrine pathology, 33 hypo/hyperthermia, 33 muscle activity, 33 patient monitoring, 33 peripheral nervous system, 32 respiratory rate, 32 therapeutic intervention, 33 Postoperative delirium (POD), 59 Postoperative nerve injury (PNI), 414 Postoperative pain, 56, 58, 59 Post-polio syndrome (PPS), 107–108 Preanesthetic checklist, 35 Preanesthetic examination, 20, 21 abdominal mass, 20 BP and oxygenation, 19 equipment, 20 infection, 19 lymph glands, 20 spinal needles clinical reports, 20 crawford needle, 21 CSF detection time, 21 CSF rate, 21 epidural needles, 21 laboratory reports, 20 needle direction, 21 Quincke-Babcock needle, 21 Tuohy needle, 21 whitacre needle, 21 www.ajlobby.com Index 499 upper airway, 20 venous access, 20 Preexisting neurologic disease, 288 Pregnancy, 223 Pressure injury, 90 Prilocaine, 341, 343, 344, 353 Procaine, 435 Propofol, 290, 321 Prothrombin time (PT), 233 Proximal limb, 273 Proximal sciatic, 194 Pruritus, 255 PubMed, 287 Pudendal nerve blockade, 306, 307 Pulse oximetry, 27 Pulsed radiofrequency, 271 Pupillary anomalies, 374 Q Quality Audit and Research Coordinators (QuARCs), 448 Quality improvement, HSRC, 448 Quantitative sudomotor axon reflex test (QSART), 118 R Radiculopathies, 114 Radiculopathy, 250 Radiofrequency (RF) neurotomy, 270–271 Randomized controlled trials (RCTs), 227, 228, 415 RCTs See randomized controlled trials (RCTs) Rectus abdominis muscle, 220 Reflexes, neurologic injury, 118 Regional anaesthesia, 10, 11, 319, 321, 324, 415, 423–425, 430, 431, 433–435, 438, 439, 446, 448–449 Australian and New Zealand registry, 423 LAST, 425 PNB-related nerve injury, 423 postoperative investigations, 423 sensory deficit, 423–424 avoiding wrong-site blocks, 478–479 awareness, 477 blocks, 219 claims, 431, 460, 461 claims experience, 430–431 complications associated, 452 definition, history, 6, malpractice claims, 483–484 medicolegal risk, 477–478 neurologic complications, 424 phrenic nerve block, 425 post WW II, 9–11 brachial plexus anesthesia, 10 electro-location, 10 epidural anesthesia, 10 nerve stimulation, 10 UK, 11 ultrasound, 10 pre-emptive analgesia, 8–9 pre-procedure verification process, 479 quality and safety, 414 regional blocks on anesthetized patients, 477–480 registry (see Registries) respiratory outcomes, 425 scope of consent, 484–485 sedation, 288–290 systems analysis approach, 438–439 time out, 479 ultrasound, 11 wrong-site block, 426 Registries, 415–416 ARAC, 415 clinical (see Clinical registry) data elements, 417 data quality control, 418 international registry of regional anesthesia, 418–419 registry imperative, 415 Reinnervation, 124–126 Relapsing-remitting disorders, 114 Remifentanil, 289, 321 Respiratory depression, 313 Respiratory distress, 426 Respiratory system, 16–17 Retrobulbar block, 370, 372–375 Retrocrural technique, 268 Retroperitoneal fibrosis, 268 Retroperitoneal hematoma, 221 Retroperitoneal injection, 221 Rivaroxaban, 145, 235 Ropivacaine, 247, 295, 296, 321, 382, 383, 386, 390, 391, 393, 394, 400–403 S Safety Canadian Standards Association, 36 CAS guidelines, 34 epidural anesthesia, 36 high reliability theory, 34 normal accidents theory, 34 patient monitoring, 35, 36 patient selection, 36 preanesthetic checklist, 35 preoperative considerations, 36 virtual reality techniques, 34 Saphenous (Adductor Canal), 194 Saphenous nerve, 194 Scarring, 116 Sedative agents, 321 Sedatives, 296 Seddon classification, 124 Seizure control, 48 Selective serotonin reuptake inhibitors (SSRI), 143, 145, 146 Sensorimotor function, 118 Sensory ataxic gait, 118 Sensory examination, neurologic injury, 118 Sensory nerve action potential (SNAP), 121, 122 Sensory nerve conduction, 121, 122 Serotonin–norepinephrine reuptake inhibitors (SNRI), 143, 145 Skin disinfection, 158–159 Skin flora contaminants, 276 Somatic nerve blocks facet joint block, 270 increased pain, 270 infection, 270 intraspinal injection, 270 SOS regional anesthesia service, 435–436 Spinal and epidural anesthesia, meningitis, 154–155 Spinal anesthesia, 248–251, 255, 256, 435–437, 442–444 advantage, alcohol and chlorhexidine, 246 www.ajlobby.com 500 Spinal anesthesia (cont.) anatomy and physiological considerations, 295–296 aseptic technique, 246 baricity, bradycardia, 248 cardiac arrest, 249 clinical observations, 295–296 cocaine, hemodynamic complications, 248 hypotension, 248 incidence of failures, 246, 247 lumbar puncture, nausea and vomiting, 249 paralysis, PDPH, 253 preoperative evaluation, 246 spinal catheters catheter breakage, 256 catheter removal, 256 cauda equina syndrome, 255 PDPH, 255 Small-gauge spinal catheter systems, 255 Strict aseptic routine, 255 spinal needles contamination, 245 sterilization process, 245 transient neurologic problems backache, 250, 251 radiculopathy, 250 TNSs, 251 treatment and prevention bradycardia, 248, 249 hypotension, 248–249 urinary retention, 249, 250 WHO safe surgery checklist, 246 Spinal cord injury autonomic hyperreflexia, 107 chronic stage, 107 spinal shock, 106 Spinal cord stimulators (SCS), 468 allergic reactions, 280 complications, 279, 280 complications of extra neural tissues, 279 device itself, 279 implantation, 279 intractable limb or trunk pain, 279 neuraxial complications, 279 randomized controlled studies, 279 Spinal hematoma, 442–444 Spinal stenosis, 114 Splanchnic vasodilatation, 267 Sprint National Anesthesia Project (SNAP), 449 Stabident® System (Fairfax Dental Inc.), 350 Staphylococcus epidermidis, 332, 392 Stellate ganglion block anomalous spread of drug, 264 anterior paratracheal approach, 262 drug effects, 264–265 intraspinal injection, 264 intravascular injection, 264 needle trauma, 263–264 postganglionic fibers, 262 preganglionic fibers, 262 prevertebral region of neck, 262 sympathetic fibers, 261 Steroid-induced myopathy, 273 Steroids, 272–273 Index Strabismus, 372, 373 Streptococcus pneumoniae, 377 Subarachnoid, 246, 247, 250, 252, 253, 255 Sub-Tenon’s anesthesia, 376, 377 Sub-Tenon’s block, 376, 377 Sufentanil, 321 Supplemental injection techniques, 350 Supraclavicular, 193 Supraclavicular brachial plexus block (SCB), 193 Supraperiosteal, 342, 344 Surgery of the century, 381 Surgical device procedure-related claims, 469 Surgical events, neurologic injury, 114–115 Sympathetic blockade techniques, 261 Sympathomimetic drugs, 248 Syringomyelia, 433 Systemic toxicity, 172 Systems analysis approach, 438 T Tachycardia, 457 Tax-paid health insurance system, 441 Tetracaine, 435 Thermometrography, 29 Thermoregulatory sweat test (TST), 118 Thienopyridine, 235 Thoracic and lumbar sympathetic blockade anatomy, 265 drug effects, 265–266 fluoroscopy-guided needle insertion, 265 intraspinal and intravascular injection, 265 lumbar region, 265 needle trauma, 265 transcutaneous approach, 265 Thoracic epidural analgesia, 447 Thoracic epidural anesthesia, 446 Thrombocytopenia, 331 Thromboelastogram (TEG), 176 Thrombosis prophylaxis, 176, 443, 444 Tibial H-reflex, 120, 121 Ticlopidine, 234, 235 TNSs See Transient neurologic symptoms (TNSs) Topical anesthesia, 3, 5, 370, 373–376 Total knee arthroplasty (TKA), 58, 383, 387–389, 392, 393 local infiltration anesthesia, 383–384 Total spinal, 312 Trachea, 263 Traditional inferior alveolar nerve block (IANB), 342, 352, 354 Transient neurologic problems, 251 backache, 250, 251 radiculopathy, 250 TNSs (see Transient neurologic symptoms (TNSs)) Transient neurologic symptoms (TNSs), 251, 252 clinical implications, 252, 253 definition, 251 etiology, 251 incidence, 251 MRI findings, 252 risk factors, 252 causes, 251 dorsal roots, 252 glucose, 252 knee surgery, 252 needle-induced trauma, 252 www.ajlobby.com Index 501 sacral maldistribution, 252 spinal cord vasoconstrictors, 252 Transient radicular impairment or transient radicular irritation (TRI), 251 Transverse rectus abdominis myocutaneous (TRAM) flaps, 405, 406 Transversus abdominis plane (TAP) block, 168, 170, 177, 219–223, 228 Trigeminal neuralgia, 270 Truncal nerve blocks, 223 Trypanophobia, 356 Tumescent anesthesia, 400 U UK National Clinical Audit program in 2013, 448 Ulcers, 116 Ultrasonography, 23, 422 Ultrasound, 10, 11, 134 electromyography, 94 guidance, 41, 44, 48, 51 indicators, 93 intraneural needle placement and injection, 93 IP approach, 93 neurologic injury indications, 134 limitations, 134 technology, 134 OOP approach, 94 surrogate markers, 93 United States Pharmacopeia (USP), 159 Universal Protocol™, 478 Upper extremity block procedures axillary, 193 infraclavicular, 193 interscalene, 192–193 supraclavicular, 193 Upper motor neuron (UMN), 106 Ureteric injury, 266 Urinary retention bladder, 249 catheterization, 249 detrusor muscle contraction, 249 disturbances of micturition, 249 etiology of postoperative, 249 and outpatient surgery, 250 types of anesthesia and operations, 249 ultrasound measurement, 249 V Vascular injury, 115 Vascular puncture, 393 Vasoconstrictor, 252 Vazirani–akinosi nerve block, 348–349 Venous thromboembolism (VTE), 235 Ventricular fibrillation, 268 Verapamil, 19 Vigilance, 23, 24, 36 Visceral nerve blocks, 269–270 celiac plexus block, 266–267 diarrhea, 267 drug effects, 268 hypotension, 267 infection, 268 needle trauma, 267–268 neurologic and neurovascular sequelae, 268 pelvic (see Pelvic visceral nerve blocks) W Warfarin therapy, 142, 143, 235 WHO safe surgery checklist, 246 Wrong site block, 446–447 Wrong-site PNBs, 426 X X-Tip® (Dentsply) anesthesia delivery system, 350 Xylocaine, 341, 343 www.ajlobby.com .. .Complications of Regional Anesthesia www.ajlobby.com Brendan T Finucane • Ban C.H Tsui Editors Complications of Regional Anesthesia Principles of Safe Practice in Local and Regional Anesthesia. .. History of Regional Anesthesia which seemed like a good place to start We also addressed the issue of Safety of Regional Anesthesia It is difficult to discuss much about regional and local anesthesia. .. progress of regional anesthesia was slow, but the technique of spinal anesthesia was always an important technique in the hands of most anesthesiologists There were a number of strong proponents of regional