1. Treatment of Acute and delayed complications of neuroaxial anesthesia

2. High Spinal Hypotension Seizures Neuropathy
Also on we will discuss:
PDPH Differential Diagnosis and Treatment

3. Hypotension

4. Hypotension after neuroaxial
Underlying Pathophysiology for Hypotension - Sympathectomy resulting in decreased SVR, decreased venous return and decreased preload
Fluid bolus is first line treatment to increase venous return and increase preload, utilizing Frank-Starling curve to increase contractility of heart
The practice of pre-hydration with mL of crystalloid has shown to decrease hypotension in some studies and in other studies it has not

5. Hypotension after neuroaxial
If hypotension does not resolve with fluid bolus, vasopressors are usually indicated to increase SVR
For long time, Ephedrine was considered the vasopressors of choice because of its alpha and beta actions, it increases HR, CO, and SVR
Phenylephrine is becoming the popular vasopressors in current literature because it has shown to cause less fetal acidosis when compared to Ephedrine

7. Bezold-Jarish Relfex
Triad of: Bradycardia, Hypotension, & Cardiovascular collapse
Caused by stretch receptors in the atrium sensing decreased preload causing slowing of the heart in order to increase preload

8. High Spinal
The three most important factors in determining block height:
Baricity of solution
Position of patient
Dose and Total volume of local anesthetic
Speed, Height of patient, and other factors have not shown an association with blockade height

9. High or Total Spinal
Fluids to combat decreased preload/venous return, need to maintain coronary and cerebral perfusion
Respiratory support (100% Facemask vs Manual assist)
Tracheal intubation if unconsciousness develops
Atropine, in increments of 0.4 mg to treat bradycardia
Ephedrine or Phenylephrine to treat low SVR and raise perfusion
May need to consider intravenous infusion of vasopressors, like epi or norepinephrine until spinal wears off
Maintain supportive measures until spinal wears off

10. CSF Lavage for High Spinal
CSF Lavage is a recognized treatment option for high spinal anesthesia
Usually done with an intrathecal epidural catheter, remove 10 mL of CSF and replace with preservative free sterile saline. No exact data exist on how many times to do this, but roughly mL will replace entire CSF volume
Significantly shortens duration of high spinal and may prevent progression to state of emergency

11. Seizures
A seizure after neuroaxial anesthesia is most likely related to systemic toxicity from intravascular absorption
Treat with supportive measures
Consider Intra-lipid 1.5 ml/Kg bolus followed by infusion of ml/kg over minutes

12. Neuropathy after Neuroaxial
First off must rule out epidrual hematoma or abcess. If patient has progressive sensory and motor weakness get MRI
Consider Transient Neurological Symptoms (TNS) - associated with Lidocaine, micro puncture catheters, obesity and lithotomy position. Remember has no motor weakness
Document any pre-existing neurological problems and post-operative changes

13. Neuropathy
Cauda Equina Syndrome - associated with continuous intrathecal catheters and 5% lidocaine.
Associated with sphincter dysfunction, sensory and motor deficits and paralysis
Can lead to permanent dysfunction

14. Differential Diagnosis and Treatment Options
PDPH
Differential Diagnosis and Treatment Options

15. Risk Factors Young, skinny females Large needle
Non-pencil point needles

16. Symptoms
Headache, that is worse when sitting or standing, and improves when laying flat
Often described as throbbing and constant, and associated with nausea/vomitting/photophobia
Onset usually within hours after puncture
Usually resolves in a week untreated

17. Differential Diagnosis
Meningitis - usually not positional and has fever
Migraine
Dehydration

18. Treatment
50% of patients who experience a "wet tap" will go on to develop PDPH. Prophylactic epidural blood patch within first 24 hours has a 71% failure rate compared to 4% failure rate after 24 hours - Be conservative

19. Conservative Measures
Fluids and Hydration - trying to increase CSF production
Encourage ambulation as tolerated, bed rest has not shown to help
Caffeine - helps by causing cerebral vasoconstriction
Analgesics
Stool softners to prevent straining and valsalva

20. Epidural Blood Patch Resolve about 70-95% of PDPH after first try
Second blood patch resolves about 70-95% of those patients that didn't respond to first
Ideally want to to choose a level below original puncture site - blood travels up (opposite of what you would think)
Usually inject mL of patients own blood into epidural space or until patient feels intense pressure
Works by coagulating and causing mass effect, thereby "closing" off the hole