Muhammad Gusno Rekozar, dr.

SpAn
Fakultas Kedokteran Universitas Batam
2016
 Anaesthesia is from the Greek and means
'loss of sensation'. Anaesthesia allows
invasive and painful procedures to be
performed with little distress to the patient.
There are three main types of
anaesthesia
1. General anaesthesia: the patient
is sedated, using either
intravenous medications or
gaseous substances, and
occasionally muscles paralysed,
requiring control of breathing by
mechanical ventilation
2. Regional anaesthesia: this can be
described as central where anaesthetic
drugs are administered directly in or
around the spinal cord, blocking the
nerves of the spinal cord (eg, epidural
or spinal anaesthesia). The main
benefit of this method is that
ventilation is not needed (provided the
block is not too high). Regional
anaesthesia can also be peripheral -
for example :
a. Plexus blocks - eg, brachial plexus.
b. Nerve blocks - eg, femoral.
c. Intravenous blocks whilst preventing venous
flow out of the region - eg, Bier's block

3. Local anaesthesia: the anaesthetic is applied

to one site, usually topically or
subcutaneously
Important complications of general
anaesthesia
 The practice of anaesthesia is
fundamental to the practice of
medicine. However, anaesthesia is
not without its problems. It is
difficult to determine exactly the
incidence of deaths directly
attributable to general anaesthetics,
as the cause of death is often
multifactorial and study methodology
varies making comparisons difficult.
 Estimates of the number of deaths where
general anaesthesia was the direct cause
have been quoted in the range from
1:10,000 operations to 1:1700 (study in
1982 by the Association of Anaesthetists
of Great Britain and Ireland).
Nonetheless, in 1987 a confidential
enquiry into perioperative deaths
revealed that very few deaths were
actually as a direct result of general
anaesthesia - incidence of 1 in 185,086
(first Confidential Enquiry into
Perioperative Deaths (CEPOD)).[1]
 Figures of anaesthetic-related
morbidity are more difficult to
determine. Estimates suggest that up
to 2% of intensive care unit
admissions at any one time are related
to anaesthetic problems.[1] Although
general anaesthesia is not without
risk, it should be remembered that it
allows necessary procedures to be
performed in a humane way - without
which the patient might otherwise die.
 Along these lines, if a patient is
high-risk for a general
anaesthetic (eg, pre-existing
comorbidities) then they should
still be referred for surgery like
any other patient. The decision to
operate and which form of
anaesthesia to use should then be
decisions made by the surgeon
and anaesthetist.
Important complications of
general anaesthesia
 Pain.
 Nausea and vomiting - up to 30% of
patients.
 Damage to teeth - 1 in 4,500 cases.
 Sore throat and laryngeal damage.
 Anaphylaxis to anaesthetic agents –
figures
such as 0.2% have been quoted.
 Cardiovascular collapse.
 Respiratory depression.
 Aspiration pneumonitis - up to 4.5%
frequency has been reported; higher
in children
 Hypothermia.
 Hypoxic brain damage.
 Nerve injury - 0.4% in general anaes-
thesia and 0.1% in regional anae-
sthesia.
 Awareness during anaesthesia - up to
0.2% of patients; higher in obstetrics
and cardiac patients.
 Embolism - air, thrombus, venous or
arterial.
 Backache.
 Headache.
 Idiosyncratic reactions related to
specific agents - eg, malignant
hyperpyrexia with suxamethonium,
succinylcholine-related apnoea.
 Iatrogenic - eg, pneumothorax related
to central line insertion.
 Death.
Some specific complications of
general anaesthesia
 Anaphylaxis
Anaphylaxis can occur to any anaesthetic
agent and in all types of anaesthesia.[1]
The severity of the reaction may vary but
features may include rash, urticaria,
bronchospasm, hypotension, angio-
oedema, and vomiting. It needs to be
carefully looked for in the pre-operative
assessment and previous general
anaesthetic charts may help.
 Patients who are suspected of an allergic
reaction should be referred for further
investigation to try to determine the
exact cause.[2] If necessary, this may
involve provocation testing or skin prick
testing and patients should be referred
to local immunologists. Anaphylaxis
needs to be promptly recognised and
managed and patients should be advised
to wear a medical emergency
identification bracelet or similar once
they recover
  Aspiration pneumonitis
A reduced level of consciousness can lead to
an unprotected airway. If the patient vomits
they can aspirate the vomitus contents into
their lungs. This can set up lung inflammation
with infection. The risk of aspiration
pneumonitis and aspiration pneumonia is
reduced by fasting for several hours prior to
the procedure and cricoid cartilage pressure
during induction of anaesthesia.[1] However,
the evidence for the use of cricoid pressure is
not clearly documented and further
investigation is required.[3]
 Other methods of reducing aspiration
pneumonitis associated with anaesthesia
are the use of metoclopramide to enhance
gastric emptying and ranitidine or proton
pump inhibitors to increase the pH of
gastric contents. The evidence for the
benefit of these methods appears
promising.[4]
 Aspiration pneumonitis may also occur in
spinal anaesthesia if the level of spinal
block is too high, leading to paralysis or
impairment of the vocal cords and
respiratory impairment.
  Peripheral nerve damage
This can occur with all the types of
anaesthesia and results from nerve
compression. The most common cause is
exaggerated positioning for prolonged
periods of time. Both the anaesthetist and the
surgeons should be aware of this potential
complication and patients should be moved
on a regular basis if possible. The severity
varies and recovery may be prolonged. The
most common nerves affected are the ulnar
nerve and the common peroneal nerve. More
rarely, the brachial plexus may be affected.[1]
 Injury to nerves can be avoided by
prevention of extreme postures for lengthy
periods during surgery. If nerve damage
occurs then patients should be followed up
and further investigations such as
electromyography may be required.[5]
 Damage to teeth
 It is now common practice to check the
teeth in the anaesthetist's pre-operative
assessment. Damage to teeth is actually the
most common cause of claims made against
anaesthetists. The tooth most commonly
affected is the upper left incisor.[6]
 Embolism

Embolism is rare during an anaesthetic

but is potentially fatal. Air embolism
occurs more commonly during
neurosurgical procedures or pelvic
operations. Prophylaxis of
thromboembolism is common and
begins pre-operatively with
thromboembolic deterrents (TEDS) and
low molecular weight heparin
(LMWH).[7]
Important complications of regional
anaesthesia
 Central regional anaesthesia was first used at
the end of the 18th century. It provided a
method of blocking afferent and efferent
nerves by injecting anaesthetic agents in
either the epidural space around the spinal
cord (epidural anaesthesia) or directly in the
cerebrospinal fluid surrounding the spinal
cord (ie in the subarachnoid space called
spinal anaesthesia). All nerves are blocked
including motor nerves, sensory nerves and
nerves of the autonomic system.
 Epidural anaesthesia takes slightly longer
than spinal anaesthesia to take effect and
provides predominantly analgesic properties.
With both, the need for muscle paralysis and
ventilation is not usually required but there is
a risk that a high block will impair
respiration, meaning that ventilation will be
necessary. Results from a review of 114
studies and a Cochrane systematic review
have shown that regional anaesthesia is
associated with reduced mortality and
reduction in serious complications in
comparison with general anaesthesia.[8][9]
 Pain - 25% of patients still experience pain
despite spinal anaesthesia.
 Post-dural headache from cerebrospinal
fluid (CSF) leak.
 Hypotension and bradycardia through
blockade of the sympathetic nervous
system.
 Limb damage from sensory and motor
block.
 Epidural or intrathecal bleed.
 Respiratory failure if block is 'too high'.
 Direct nerve damage.
 Hypothermia.
 Damage to the spinal cord - may be
transient or permanent.
 Spinal infection.
 Aseptic meningitis.
 Haematoma of the spinal cord - enhanced
by use of LMWH pre-operatively.
 Anaphylaxis.
 Urinary retention.
 Spinal cord infarction.
 Anaesthetic intoxication.[10]
Some specific complications of
regional anaesthesia.
 Post-dural puncture headache
Post-dural puncture headache is very
common after spinal anaesthesia and
especially in young adults and obstetrics. The
headache results from CSF leak from the
puncture site. It is enhanced by use of larger-
gauge needles and reduced by pencil-tipped
needles. Presenting symptoms may include
headache, photophobia, vomiting and
dizziness.[11]
 Post-dural puncture headache is usually
treated with analgesia, bed rest and adequate
hydration. The evidence does not suggest that
bed rest prevents or changes the outcome.[12]
[13] Occasionally epidural blood patch is used
where 15 ml of the patient's blood are injected at
the site of the meningeal tear.[11] Caffeine is also
used and acts as a stimulant of the CNS and has
shown benefit.[14] Other medications with
benefit include gabapentin, theophylline and
hydrocortisone.[14] Subcutaneous sumatriptan,
adrenocorticotrophic hormone (ACTH) and
epidural saline have not shown consistent
benefits.[12][14]
Total spinal block

 Total spinal block can occur with the

injection of large amounts of anaesthetic
agents into the spinal cord. It is detected
by a high sensory level and rapid muscle
paralysis. The block moves up the spinal
cord so that respiratory embarrassment
may occur, as can unconsciousness. In
these situations the patient needs
prompt assessment and may need to be
intubated and ventilated until the spinal
block wears off.
 Hypotension

 Up to half of patients receiving spinal

anaesthesia will develop transient
hypotension as sympathetic nerves are
blocked. This usually responds to
prompt fluid replacement, usually
starting with crystalloids followed by
colloids. Occasionally hypotension can
be severe and may require
vasopressors along with
fluids.[10][15]
 Care must be taken in patients with a
cardiac history, as they may develop
myocardial ischaemia with minor drops in
blood pressure.[16] It is suggested that
heart rate variability prior to spinal
anaesthesia represents autonomic
dysfunction and may help determine
patients who are more likely to develop
hypotension.[17]
 Cases of bradycardia with asystole leading
to cardiac arrest have also occurred and it
appears the underlying aetiology is
complicated and not just related to
autonomic dysfunction.
Neurological deficits
 Cauda equina syndrome may occur and can
be transient or permanent. This is a common
reason for patients to refuse spinal
anaesthesia. There may also be traumatic
injury to the spinal cord.[10][18]
 Adhesive arachnoiditis is a longer-term
sequela of spinal anaesthesia, occurring
weeks and even months later.[18] It is
characterised by proliferation of the
meninges and vasoconstriction of spinal cord
blood vessels. This results in gradual sensory
and motor deficits from ischaemia and
infarction of the spinal cord.[19]
Important complications of local
anaesthesia
 Pain
 Bleeding and haematoma
formation.
 Nerve injury due to direct
injury.
 Infection.
 Ischaemic necrosis.
 All forms of anaesthetics are invasive
to a patient and therefore consent
should be obtained as for other
procedures. Ideally patients should be
given a leaflet regarding anaesthesia
and then counselled regarding the
intended benefits and the risks of
anaesthesia. In a general practice
setting it will be the responsibility of
the clinician who administers the local
anaesthesia to ensure good, non-
coercive consent is obtained.
1. Bombeli T, Spahn DR; Updates in perioperative
coagulation: physiology and management of
thromboembolism and haemorrhage.; Br J Anaesth.
2004 Aug;93(2):275-87. Epub 2004 Jun 25.
2. Rodgers A, Walker N, Schug S, et al; Reduction of
postoperative mortality and morbidity with epidural
or spinal anaesthesia: results from overview of
randomised trials.; BMJ. 2000 Dec
16;321(7275):1493.
3. Guay J, Choi P, Suresh S, et al; Neuraxial blockade
for the prevention of postoperative mortality and
major morbidity: an overview of Cochrane
systematic reviews. Cochrane Database Syst Rev.
2014 Jan 25;1:CD010108. doi:
10.1002/14651858.CD010108.pub2.
4. Picard J, Meek T; Complications of regional
anaesthesia. Anaesthesia. 2010 Apr;65 Suppl
1:105-15. doi: 10.1111/j.1365-
2044.2009.06205.x.
Further reading & references
1. Aitkenhead AR; Injuries associated with
anaesthesia. A global perspective.; Br J Anaesth.
2005 Jul;95(1):95-109. Epub 2005 May 20.
2. Kroigaard M, Garvey LH, Menne T, et al; Allergic
reactions in anaesthesia: are suspected causes
confirmed on subsequent testing?; Br J Anaesth.
2005 Oct;95(4):468-71. Epub 2005 Aug 12.
3. Butler J, Sen A; Best evidence topic report. Cricoid
pressure in emergency rapid sequence induction.
Emerg Med J. 2005 Nov;22(11):815-6.
4. Hong JY; Effects of metoclopramide and ranitidine
on preoperative gastric contents in day-case
surgery.; Yonsei Med J. 2006 Jun 30;47(3):315-8.
5. Borgeat A; Neurologic deficit after peripheral
nerve block: what to do?; Minerva Anestesiol.
2005 Jun;71(6):353-5.
6. Kuczkowski KM; Post-dural puncture headache in the
obstetric patient: an old problem. New solutions.;
Minerva Anestesiol. 2004 Dec;70(12):823-30.
7. Turnbull DK, Shepherd DB; Post-dural puncture
headache: pathogenesis, prevention and treatment.;
Br J Anaesth. 2003 Nov;91(5):718-29.
8. Arevalo-Rodriguez I, Ciapponi A, Munoz L, et al;
Posture
and fluids for preventing post-dural puncture
headache.
Database Syst Rev. 2013 Jul 12;7:CD009199.
doi: 10.1002/14651858.CD009199.pub2.
9. Basurto Ona X, Martinez Garcia L, Sola I, et al; Drug
therapy for treating post-dural puncture headache.
Cochrane Database Syst Rev. 2011 Aug
10;(8):CD007887.
doi: 10.1002/14651858.CD007887.pub2.
10. Complications of Regional Anaesthesia;
UK, 2005
11. Jin F, Chung F; Minim.; Mt Sinai J Med. 2002 Jan-
Mar;69(1-2):55-6.
12. Killeen T, Kamat A, Walsh D, et al; Severe izing
perioperative adverse events in the elderly.;
Br J Anaesth. 2001 Oct;87(4):608-24.
13. Hanss R, Bein B, Weseloh H, et al; Heart rate variability
predicts severe hypotension after spinal anesthesia.;
Anesthesiology. 2006 Mar;104(3):537-45.
14. Hyderally H; Complications of spinal anesthesiaadhesive
arachnoiditis resulting in progressive paraplegia
following
obstetric spinal anaesthesia: a case report and review.
Anaesthesia. 2012 Dec;67(12):1386-94. doi:
10.1111/anae.12017. Epub 2012 Oct 12.
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