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Complications of Regional Blocks

Practice Essentials

Spinal epidural hematoma after regional block

Signs and symptoms of spinal epidural hematoma after regional block include the following:

Progressive loss of sensation and weakness in the lower extremities bilaterally

Loss of bowel and bladder function

Severe back pain (often not the presenting symptom)

Management of suspected spinal epidural hematoma includes the following:

Emergency magnetic resonance imaging (MRI) of the spine for diagnosis

If MRI is positive for epidural hematoma, notify neurosurgery immediately

Definitive treatment consists of surgical decompression of the spine and evacuation of the hematoma

Measures for prevention of spinal epidural hematoma include the following:

Proceed with caution in patients with known coagulation disorders, performing a careful risk-benefit analysis

Follow the guidelines developed by the American Society of Regional Anesthesia (ASRA) for regional anesthesia in patients receiving antithrombotic or thrombolytic therapy

Local anesthetic systemic toxicity after regional block

Signs and symptoms of local anesthetic systemic toxicity (LAST) after regional block include the following:

Early neurologic symptoms – Tinnitus, oral numbness, metallic taste, lightheadedness

Late neurologic symptoms – Seizures, respiratory arrest, coma

Cardiac manifestations – Arrhythmias, cardiac arrest

Management of LAST includes the following:

Airway management

Treatment of seizures with benzodiazepines

If cardiac arrest occurs – Modified advanced cardiac life support (ACLS) protocol (lower doses of epinephrine, < 1 μg/kg); avoidance of vasopressin, calcium-channel blockers, beta blockers, and local anesthetics

Lipid emulsion (20%) therapy (patient < 70 kg) – Administer bolus of 1.5 mL/kg over 2-3 minutes; then infuse at 0.25 mL/kg/min (continue for 10 minutes after return of cardiovascular stability); repeat bolus if cardiovascular collapse persists; double the infusion rate

Lipid emulsion (20%) therapy (patient >70 kg) – Give bolus of 100 mL over 2-3 minutes; then infuse 250 mL over 15-20 minutes; repeat bolus if cardiovascular collapse persists; infuse 500 mL over 15-20 minutes; upper limit for total dose is ~10 mL/kg over 30 minutes

Report LAST events to www.lipidrescue.org and www.lipidregistry.org

Measures for prevention of LAST include the following:

Use the lowest effective dose of local anesthetic possible

Recognize factors that may increase the risk of LAST (eg, medical conditions and medications)

Use a pharmacologic marker to show immediate signs of intravascular injection

Aspirate before
each injection of local anesthetic

Inject local anesthetic incrementally, and watch for signs of toxicity in between injections

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