Incidence of Epidural Hematoma, Infection, and Neurologic Injury in Obstetric Patients with Epidural Analgesia/Anesthesia
Ruppen, Wilhelm M.D.*; Derry, Sheena M.A.†; McQuay, Henry D.M.‡; Moore, R Andrew D.Sc.§
Of the 4 million annual births in the United States, 2.4 million involve epidural analgesia. Serious adverse events are rare but are important in young women. Robust estimates for the risk of harm are not available. Data for superficial and deep infections, hematoma, and transient and permanent neurologic injury were obtained from studies reporting adverse events with obstetric epidural analgesia, and incidence presented as individual risk for a woman, number of events per million women, and percentage incidence. A total of 1.37 million women received an epidural for childbirth, reported in 27 articles. Most information (85% of women) was in larger (> 10,000 women) studies published after 1990, with risk estimates as follows: epidural hematoma, 1 in 168,000; deep epidural infection, 1 in 145,000; persistent neurologic injury, 1 in 240,000; and transient neurologic injury, 1 in 6,700. Earlier and smaller studies produced significantly higher risk estimates for transient neurologic injury plus injury of unknown duration.
Click on the links below to access all the ArticlePlus for this article.
Please note that ArticlePlus files may launch a viewer application outside of your web browser.
IN 2003, there were more than 4 million births in the United States.∥
An increasing number of women choose an epidural, usually a lumbar epidural catheter, to alleviate labor pain. The obstetric anesthesia workforce survey1
showed that approximately 60% of women in the United States giving birth in larger hospitals (> 1,500 births a year) have an epidural; this number decreases to 42% in smaller hospitals (100-500 births). Approximately 2.4 million women a year have an epidural for childbirth. In the United Kingdom, the epidural rate is approximately 35%; in Canada, it is 45%#
; and in France in 1996, it was 51%,1
although it is difficult to obtain exact figures.
Although epidural analgesia and anesthesia is generally safe, serious adverse events can occur. Because of the large number of healthy young women having epidurals during labor, even rare adverse events are important, especially if they are serious. Any negative impact on quality of life, together with the economic costs of a serious adverse event, is especially important in this patient group.
The aim of this meta-analysis was to estimate the incidence of rare but serious problems occurring with epidural analgesia in obstetric practice, namely epidural hematoma, epidural infection, and persistent and transient neurologic injuries.
Materials and Methods
We searched PubMed (from 1966), EMBASE (from 1980), and MEDLINE (from 1966) to February 2005, with no restrictions on language or type of study (detailed search strategy in supplementary file 1, available on the Anesthesiology Web site at http://www.anesthesiology.org
). Five journals (Anesthesiology, Anesthesia & Analgesia, British Journal of Anesthesia, Anesthesia
, and Acta Anaesthesiologica Scandinavica
) were hand-searched from mid-1999 to 2005. Reference lists were checked for additional studies (fig. 1
Full paper copies were obtained for all studies not eliminated after reading title and abstract. We then selected those reporting on at least 200 obstetric patients, with numerical data for serious adverse effects such as hematoma, infection, and neurologic injuries. We took definitions of adverse events as described by the authors of the individual studies. For infections, we were interested in both superficial infections (e.g., skin infection around the catheter site) and deep infections (in the epidural space). For neurologic injuries, we were interested in those that were transient (resolved within 1yr) and persistent (not resolved within 1 yr). Persistence of neurologic deficit was likely to be a proxy for seriousness, which we also looked for.
Information about the type of study, patients, intervention, and numbers of patients experiencing individual adverse outcomes was tabulated. We did not use quality-scoring systems. QUOROM (Quality of Reporting of Meta-analyses) guidelines were followed where applicable. For these calculations, a study was included only if it mentioned that an adverse event was present or definitely not present; studies not mentioning the adverse event were omitted from that particular calculation. We planned to perform sensitivity analyses for larger (> 10,000 women) versus
smaller studies and for older (published before 1990) versus
recent studies. In sensitivity analyses, relative risk was calculated with 95% confidence intervals using a fixed effects model,2
with no statistically significant difference assumed when the 95% confidence interval included unity.
It was our previous intent to present the information on rare events in several ways: the risk to an individual woman as odds, the number of events per million women, and percent of women with the complication. In addition, we sought to present information on the annual incidence of these events for several countries, based on number of live births and estimates of epidural rates.
We identified a large number of articles (1,269), with an eventual list of 267 articles relating to epidural complications. Thirty-eight related to obstetrics, of which 11 (references in supplementary file 2, available on the Anesthesiology Web site at http://www.anesthesiology.org
) were excluded (fig. 1
). Of the 27 included, only 5 studies (19% of studies, 37% of women) were identified by electronic searches, 2 (7%, 0.1%) were identified by hand searching, and 20 (74%, 63%) were identified by examination of reference lists and reviews.
The 27 articles3–29
reported on 1.37 million women having an epidural for childbirth (supplementary file 3 contains details of patients, study design, and detailed results, available on the Anesthesiology Web site at http://www.anesthesiology.org
). Eleven studies6,9,13,14,19,22–24,26–28
with 1.31 million women in all each reported on more than 10,000 women (range, 10,995–506,000). Sixteen4–6,8,11,12,14,17–19,22–24,26,27,29
with 1.19 million women were published after 1990. The 7 larger post-1990 studies6,14,19,22,23,26,27
had 1.16 million women, 85% of the total.
Two randomized trials8,11
had information on 3,330 women, 7 prospective cohorts4,6,7,14,18,22,24
had information on 58,945 women, 18 retrospective cohorts5,9,10,12,13,15–21,23,25–29
had information on 1,304,817 women, and 1 cohort17
(4,162 women) combined both prospective and retrospective information. One article3
reported prospective and retrospective information separately. Twenty prospective and retrospective cohorts were based either on a population or on a consecutive series without selection, while the remaining 5 cohort studies6,9,12,14,18
(10,126 women) made no statement about avoiding selection.
with 1.1 million women reported a total of six epidural hematomas (table 1
), with one25
(80,000 women) published before 1990. All six hematomas were reported in three large studies,19,23,26
each of at least 200,000 women and reported since 1990. For no case was any clear outcome described. The overall rate of epidural hematoma was 1 in 183,000 women, or 5 per million. Rates in larger post-1990 studies were 1 in 168,000 women, or 6 per million (table 1
Only two studies4,16
(1,294 women) reported on superficial infection stating no events. Eleven cases of deep epidural infection were reported in 13 studies4–6,9,10,14,16,17,19,22,23,26,27
with 1.2 million women (table 1
). For none of these events was there clear description of the clinical consequences. The overall rate of deep infection was 1 in 110,000 women, or 9 per million. Rates in larger post-1990 studies were 1 in 145,000 women, or 7 per million.
Persistent Neurologic Injury
Nine studies with 770,000 women3,5,11,13,19,20,24,26,28
reported three cases of persistent neurologic injury (table 1
). None of these was clearly related to epidural hematoma or epidural infection. The overall rate of persistent neurologic injury was 1 in 257,000 women, or 4 per million. Rates in larger post-1990 studies were 1 in 237,000 women, or 4 per million.
Transient Neurologic Injury
with 987,000 women reported 254 cases of transient neurologic injury lasting less than 1 yr (table 1
). Definitions of neurologic damage were not always clear; in almost all cases, only symptoms were described, without any link between the injury and either epidural or childbirth. The overall rate of transient neurologic injury was 1 in 3,900 women, or 257 per million. Rates in larger post-1990 studies were 1 in 5,537, or 180 per million.
Transient Neurologic Injury plus Injury of Unknown Duration
with 290,000 women reported 34 neurologic injuries of unspecified duration. Because it is probable that these were transient, we analyzed them together with known transient injuries (table 1
). Combining the information on 1,250,000 women in 20 studies, the overall rate of transient neurologic injury or injury of unknown duration was 1 in 4,300 women, or 230 per million. Rates in larger post-1990 studies were 1 in 6,700 women, or 150 per million. Using only these newer, larger studies with 92% of all the women studied produced a significantly lower estimate for the event rate than all data combined, with a relative risk of 0.65 (0.54–0.78).
We performed sensitivity analysis only for transient neurologic injury or injury of unknown duration because this had the largest number of events. In individual studies, rates of transient neurologic injury or injury of unknown duration were as low as 1 per million and as high as 1,000 per million (fig. 2
). Predictably, most of the variability was in the small studies, and the largest were close to the overall average. Eleven smaller studies (< 10,000 women)3,7,10,11,15,16,18,20,21,24,29
recorded 111 events in 48,059 women, or 2,300 per million. Nine larger studies (> 10,000 women)6,9,14,19,22,23,26–28
recorded 177 events in 1,202,659 women, or 150 per million. Larger studies gave a significantly lower rate of transient neurologic injuries plus injuries of unknown duration than did smaller studies, with a relative risk of 0.06 (95% confidence interval, 0.05–0.08), a 15-fold difference.
Nine studies published before 19903,7,9,10,15,16,20,21,28
reported 72 events in 88,182 women, 820 per million. Eleven studies published after 19906,11,14,18,19,22–24,26,27,29
reported 217 events in 1,173,531 women, 190 per million. Post-1990 studies gave a significantly lower rate of transient neurologic injuries plus injuries of unknown duration than did earlier studies, with a relative risk of 0.23 (0.17–0.30), a fourfold difference.
Pregnant women are usually young and healthy, and the expectation is that modern childbirth is relatively safe for mother and baby. Any intervention in childbirth, for example, to provide good analgesia, should carry minimal risk. Rare but serious adverse events are important in this circumstance.
To calculate the incidence of rare adverse events requires large numbers of patients. Rare adverse events are more likely to be identified in large observational studies than in small randomized trials. These observational studies should report on a whole obstetric population to eliminate selection bias.
This analysis sought studies reporting adverse events of various sorts associated with the use of epidural analgesia in obstetrics. It found 27 studies with 1.4 million women, compared with a previous review containing 11 studies and 681,000 women.30
Almost all of the studies were prospective or retrospective cohorts, with only 10,000 of 1.4 million women (0.07%) in 5 studies that were not identified clearly as unselected population cohorts or randomized trials. Almost all of the information (85% of women studied) was in the larger post-1990 studies. For transient neurologic injury plus neurologic injury of unknown duration, there were sufficient numbers of events for sensitivity analyses. Smaller studies (< 10,000 women) compared with larger ones, and older studies (before 1990) compared with newer ones, overestimated adverse events by 15- and 4-fold, respectively.
Only 6 epidural hematomas, 11 deep epidural infections, and 3 persistent neurologic injuries were reported. This is inadequate to produce a robust estimate of event rates; 95% confidence intervals were 1–11 per million for epidural hematoma, 2–12 per million for deep epidural infection, and 0–8 per million for persistent neurologic injury. More events, perhaps 25–50, would be needed to narrow these confidence intervals, implying studying 6 million to 12 million women for a robust estimate for persistent neurologic injury. Since our searches in February 2005, one further prospective study of cesarean delivery31
found no cases of epidural hematoma or infection among 15,443 women having an epidural.
The risk associated with these adverse outcomes was calculated and presented in different ways (table 1
). The use of several different ways of conveying information about rare adverse events is important, because we know that individuals overestimate risk when presented verbally by up to 400-fold.32
These event rates can be used to estimate the likely burden for a whole country, depending on the number of live births and the use of epidural analgesia in obstetrics. We obtained estimates for number of births and epidural rates for the United States, Canada, United Kingdom, France, and Switzerland. Using realistic figures for epidural rates, and the overall rates of adverse events, the impact was as high as nine cases of persistent neurologic injury in the United States per year, to one every 10 yr in Switzerland (table 2
). Such calculations may be of use in developing guidance or critical incident reporting rules. For rare events, even the largest hospital would be unlikely to see one in a decade.
Transient neurologic injuries resolving within 1 yr were more common. Although few of these could clearly be linked unequivocally with the epidural, they occurred in 1 in 4,300 women. This rate could be inflated by small studies, because larger studies had lower event rates (fig. 2
Neurologic deficits after childbirth may have many causes, and all of these rare adverse events could occur spontaneously or because of childbirth.3,21,33–38
Lack of evidence of causation is a weakness of this study, because in almost no case was there a definite link between the adverse event and the epidural. Usubiaga39
reported several cases in which epidurals were unjustifiably linked to harm in nonobstetric cases. Murray40
reported 95 cases with neurologic damage in obstetrics with and without epidurals. He found that 85% of cases of neurologic damage occurred with forceps delivery. Doblar and Schumacher41
report one case of spontaneous epidural hematoma, as well as six other reports of spontaneous epidural hematoma during pregnancy, all with some neurologic symptoms. Male and Martin42
and Kitching and Rice43
reported spontaneous puerperal spinal epidural abscesses without epidural anesthesia.
There are other potential weaknesses. Searching for observational studies is not as simple as for randomized trials. Lemeshow et al.44
found that searching in only one database yielded only 60–80% of relevant observational studies, and here, searching several electronic databases with a comprehensive search strategy yielded only 5 of 27 studies (18%). Most of the studies were found from reference lists and review articles. Whether this is a special case cannot be known, but the finding has implications for adverse event research. Serious adverse events may also be underreported. Cultural, social, and legal considerations, especially relating to epidurals and childbirth, might also restrict reporting in the medical literature.
This analysis used transient, less than 1 yr, and permanent, more than 1 yr, to categorize neurologic damage. Although time is clearly important, the seriousness of the damage, on a spectrum of pathology from skin numbness through to paraplegia, should also be borne in mind. We were unable to report on seriousness.
Several questions could not be answered by this review. We found no information about risk factors for adverse events, or information linking events such as epidural hematoma or infection to neurologic injury. The types of study sought were unlikely to provide this information, which is more likely to be found in case reports. There was also no information about the clinical consequences of these adverse events, although in studies not restricted to obstetric populations, complete recovery was achieved in only 40% of 561 cases of spinal hematoma,45
and a good outcome occurred in 26 of 40 patients with an epidural abscess.46
Finally, our results relate only to childbirth. Different results might be expected in older patients with epidurals for a short period for surgical procedures, or patients with long-term epidurals for chronic pain relief. Clinicians should be aware of the possibility of serious complications of epidural analgesia in obstetrics, however rare. We provide best available estimates for some serious adverse events.
The authors thank Oksana Kirichek (Data Manager, Medical Oncology Unit, Cancer Research UK, Oxford, United Kingdom) for her help in translation of articles written in Russian; and François Clergue, M.D. (Professor/Chairman, Department of Anaesthesiology, Pharmacology, and Surgical Intensive Care, Geneva University Hospitals, Geneva, Switzerland), and Markus Schneider, M.D. (Professor, University Hospital Basel, Basel, Switzerland), for helpful discussions.
1. Clergue F, Auroy Y, Pequignot F, Jougla E, Lienhart A, Laxenaire MC: French survey of anesthesia in 1996. Anesthesiology 1999; 91:1509–20
2. Morris JA, Gardner MJ: Calculating confidence intervals for relative risk, odds ratios and standardised ratios and rates, Statistics with Confidence: Confidence Intervals and Statistical Guidelines. Edited by Gardner MJ, Altman DG. London, BMJ, 1995, pp 50–63
3. Abouleish E: Neurologic complications following epidural analgesia in obstetrics. Reg Anesth 1982; 7:119–24
4. Adam MN, Dinulescu T, Mathieu P, Giacomini T, Le Pennec MP: Comparaison de l'efficacite de deux antiseptiques dans la prevention de l'infection liee aux catheters periduraux [Comparison of the efficacy of 2 antiseptic solutions in the prevention of infection from peridural catheters]. Cah Anesthesiol 1996; 44:465–7
5. Albright GA, Forster RM: The safety and efficacy of combined spinal and epidural analgesia/anesthesia (6,002 blocks) in a community hospital. Reg Anesth Pain Med 1999; 24:117–25
6. Auroy Y, Benhamou D, Bargues L, Ecoffey C, Falissard B, Mercier FJ, Bouaziz H, Samii K: Major complications of regional anesthesia in France: The SOS Regional Anesthesia Hotline Service. Anesthesiology 2002; 97:1274–80
7. Bleyaert A, Soetens M, Vaes L, Van Steenberge, AL, Van der Donck A: Bupivacaine, 0.125 per cent, in obstetric epidural analgesia: Experience in three thousand cases. Anesthesiology 1979; 51:435–8
8. CLASP: A randomised trial of low-dose aspirin for the prevention and treatment of pre-eclampsia among 9364 pregnant women. CLASP (Collaborative Low-dose Aspirin Study in Pregnancy) Collaborative Group. Lancet 1994; 343:619–29
9. Crawford JS: Some maternal complications of epidural analgesia for labour. Anaesthesia 1985; 40:1219–25
10. Eisen SM, Rosen N, Winesanker H, Hellman K, Axelrod HI, Rotenberg M, Relle A, Sheffman E: The routine use of lumbar epidural anaesthesia in obstetrics: A clinical review of 9,532 cases. Can Anaesth Soc J 1960; 7:280–9
11. Evron S, Sessler D, Sadan O, Boaz M, Glezerman M, Ezri T: Identification of the epidural space: Loss of resistance with air, lidocaine, or the combination of air and lidocaine. Anesth Analg 2004; 99:245–50
12. Guasch Arevalo E, Suarez Cobian A: Platelet count and hematic punction with epidural block in obstetrics [in Spanish]. Rev Esp Anestesiol Reanim 2003; 50:130–4
13. Hellmann K: Epidural anaesthesia in obstetrics: A second look at 26,127 cases. Can Anaesth Soc J 1965; 12:398–404
14. Holdcroft A, Gibberd FB, Hargrove RL, Hawkins DF, Dellaportas CI: Neurological complications associated with pregnancy. Br J Anaesth 1995; 75:522–6
15. Holdcroft A, Morgan M: Maternal complications of obstetric epidural analgesia. Anaesth Intensive Care 1976; 4:108–12
16. Kandel PF, Spoerel WE, Kinch RA: Continuous epidural analgesia for labour and delivery: Review of 1000 cases. Can Med Assoc J 1966; 95:947–53
17. Kindler C, Seeberger M, Siegemund M, Schneider M: Extradural abscess complicating lumbar extradural anaesthesia and analgesia in an obstetric patient. Acta Anaesthesiol Scand 1996; 40:858–61
18. MacArthur C, Lewis M, Knox EG: Investigation of long term problems after obstetric epidural anaesthesia. BMJ 1992; 304:1279–82
19. Moen V, Dahlgren N, Irestedt L: Severe neurological complications after central neuraxial blockades in Sweden 1990–1999. Anesthesiology 2004; 101:950–9
20. Moore DC, Bridenbaugh LD, Thompson GE, Balfour RI, Horton WG: Bupivacaine: A review of 11,080 cases. Anesth Analg 1978; 57:42–53
21. Ong BY, Cohen MM, Esmail A, Cumming M, Kozody R, Palahniuk RJ: Paresthesias and motor dysfunction after labor and delivery. Anesth Analg 1987; 66:18–22
22. Paech MJ, Godkin R, Webster S: Complications of obstetric epidural analgesia and anaesthesia: A prospective analysis of 10,995 cases. Int J Obstet Anesth 1998; 7:5–11
23. Palot M, Visseaux H, Botmans C, Pire JC: Epidemiology of complications of obstetrical epidural analgesia [in French]. Cah Anesthesiol 1994; 42:229–33
24. Richardson MG, Wissler RN: The effects of needle bevel orientation during epidural catheter insertion in laboring parturients. Anesth Analg 1999; 88:352–6
25. Rolbin SH, Abbott D, Musclow E, Papsin F, Lie LM, Freedman J: Epidural anesthesia in pregnant patients with low platelet counts. Obstet Gynecol 1988; 71:918–20
26. Scott DB, Hibbard BM: Serious non-fatal complications associated with extradural block in obstetric practice. Br J Anaesth 1990; 64:537–41
27. Scott DB, Tunstall ME: Serious complications associated with epidural/spinal blockade in obstetrics: A two-year prospective study. Int J Obstet Anesth 1995; 4:133–9
28. Vaes L: Regional anesthesia: how safe? A review of 20,590 cases. Acta Anaesthesiol Belg 1988; 39:175–6
29. Yuen EC, Layzer RB, Weitz SR, Olney RK: Neurologic complications of lumbar epidural anesthesia and analgesia. Neurology 1995; 45:1795–801
30. Loo CC, Dahlgren G, Irestedt L: Neurological complications in obstetric regional anaesthesia. Int J Obstet Anesth 2000; 9:99–124
31. Bloom SL, Spong CY, Weiner SJ, Landon MB, Rouse DJ, Varner MW, Moawad AH, Caritis SN, Harper M, Wapner RJ, Sorokin Y, Miodovnik M, O'Sullivan MJ, Sibai B, Langer O, Gabbe SG, National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network: Complications of anesthesia for cesarean delivery. Obstet Gynecol 2005; 106:281–7
32. Berry DC, Knapp P, Raynor DK: Provision of information about drug side-effects to patients. Lancet 2002; 359:853–4
33. Besmer I, Schupfer G, Hodel D, Johr M: Postpartum neurologic complications following delivery with peridural analgesia: Case report with literature review [in German]. Anaesthesist 2001; 50:852–5
34. Bademosi O, Osuntokun BO, Van de Werd HJ, Bademosi AK, Ojo OA: Obstetric neuropraxia in the Nigerian African. Int J Gynaecol Obstet 1980; 17:611–4
35. Bromage PR: Nerve injury and paralysis related to spinal and epidural anesthesia. Reg Anesth 1993; 18:481–4
36. Hill EC: Maternal obstetric paralysis. Am J Obstet Gynecol 1962; 83:1452–60
37. Bidzinski J: Spontaneous spinal epidural hematoma during pregnancy: Case report. J Neurosurg 1966; 24:1017
38. Yonekawa Y, Mehdorn HM, Nishikawa M: Spontaneous spinal epidural hematoma during pregnancy. Surg Neurol 1975; 3:327–8
39. Usubiaga JE: Neurological complications following epidural anesthesia. Int Anesthesiol Clin 1975; 13:1–153
40. Murray RR: Maternal obstetrical paralysis. Am J Obstet Gynecol 1964; 88:399–403
41. Doblar DD, Schumacher SD: Spontaneous acute thoracic epidural hematoma causing paraplegia in a patient with severe preeclampsia in early labor. Int J Obstet Anesth 2005; 14:256–60
42. Male CG, Martin R: Puerperal spinal epidural abscess. Lancet 1973; 1:608–9
43. Kitching AJ, Rice AS: Extradural abscess in the postpartum period. Br J Anaesth 1993; 70:703–4
44. Lemeshow AR, Blum RE, Berlin JA, Stoto MA, Colditz GA: Searching one or two databases was insufficient for meta-analysis of observational studies. J Clin Epidemiol 2005; 58:867–73
45. Kreppel D, Antoniadis G, Seeling W: Spinal hematoma: A literature survey with meta-analysis of 613 patients. Neurosurg Rev 2003; 26:1–49
46. Nussbaum ES, Rigamonti D, Standiford H, Numaguchi Y, Wolf AL, Robinson WL: Spinal epidural abscess: A report of 40 cases and review. Surg Neurol 1992; 38:225–31
∥ Service USDoHH: United States birth rate reaches record low. 2003. Available at: http://pregnancyaboutcom/gi/dynamic/offsitehtm?site=http://wwwhhsgov/news/press/2003pres/20030625html
. Accessed September 23, 2005. Cited Here...
# Information CIfH: A regional profile, Giving Birth in Canada. 2004. Available at: http://dsp-psd.pwgsc.gc.ca/Collection/H118-25-2004E.pdf
. Accessed October 1, 2005. Cited Here...
This article has been cited 42 time(s).
Bmc AnesthesiologyIncidence and predictors of immediate complications following perioperative non-obstetric epidural puncturesBmc Anesthesiology
AnaesthesiaPain measures and cut-offs - no worse than mild pain as a simple, universal outcomeAnaesthesia
British Journal of AnaesthesiaAnalysis of individual patient data from clinical trials: epidural morphine for postoperative painBritish Journal of Anaesthesia
Heart Surgery ForumEpidural analgesia in cardiac surgery: An updated risk assessmentHeart Surgery Forum
Canadian Journal of Anaesthesia-Journal Canadien D Anesthesie
Challenges in obstetric anesthesia and analgesia
Canadian Journal of Anaesthesia-Journal Canadien D Anesthesie, 55(6):
New England Journal of Medicine
Epidural Analgesia for Labor and Delivery
New England Journal of Medicine, 362():
Clinical Orthopaedics and Related ResearchPostspinal anesthesia osteomyelitis of the lumbar spineClinical Orthopaedics and Related Research
AnaesthesistIncidence of infection from catheter procedures for regional anesthesia First results from the network of DGAI and BDAAnaesthesist
Anaesthesia and Intensive Care
Postpartum septic sacroiliitis coincident with labour epidural analgesia
Anaesthesia and Intensive Care, 36(6):
Acta Anaesthesiologica ScandinavicaScandinavian guidelines for neuraxial block and disturbed haemostasis: replacing wishful thinking with evidence based cautionActa Anaesthesiologica Scandinavica
Anesthesia and AnalgesiaEpidemiology of Anesthesia-Related Complications in Labor and Delivery, New York State, 2002-2005Anesthesia and Analgesia
Arthritis Research & TherapyWhat do we know about communicating risk? A brief review and suggestion for contextualising serious, but rare, risk, and the example of cox-2 selective and non-selective NSAIDsArthritis Research & Therapy
Women in labor and the quality obstetric care system: the role of evidence-based neuraxial analgesia
Minerva Anestesiologica, 75(3):
AnaesthesiaDo we need written consent for labor analgesia?Anaesthesia
Regional Anesthesia and Pain MedicineSafety During Regional Anesthesia What Do We Know and How Can We Improve Our Practice?Regional Anesthesia and Pain Medicine
International Journal of Obstetric AnesthesiaObstetric epidural catheter-related infections at a major teaching hospital: a retrospective case seriesInternational Journal of Obstetric Anesthesia
International Journal of Obstetric AnesthesiaNeuraxial anesthesia in obstetric patients receiving anticoagulant and antithrombotic drugsInternational Journal of Obstetric Anesthesia
Bmc GastroenterologyMortality with upper gastrointestinal bleeding and perforation: effects of time and NSAID useBmc Gastroenterology
Neurological SciencesThoracic extradural haematoma after epidural anaesthesiaNeurological Sciences
Bmc Musculoskeletal DisordersNonsteroidal anti-inflammatory drugs (NSAIDs), cyxlooxygenase-2 selective inhibitors (coxibs) and gastrointestinal harm: review of clinical trials and clinical practiceBmc Musculoskeletal Disorders
Anasthesiologie Intensivmedizin Notfallmedizin Schmerztherapie
Severe complications through regional analgesia procedure - Symptoms, diagnosis and therapy
Anasthesiologie Intensivmedizin Notfallmedizin Schmerztherapie, 42(1):
Transplantation ProceedingsEpidural anesthesia? No of courseTransplantation Proceedings
Vasa-Journal of Vascular Diseases
"S3 Guideline - Prophylaxis of venous thromboembolism"
Vasa-Journal of Vascular Diseases, 38():
Anesthesia and AnalgesiaNeuraxial Techniques in Obstetric and Non-Obstetric Patients with Common Bleeding DiathesesAnesthesia and Analgesia
British Journal of HaematologyThe risk of spinal haematoma following neuraxial anaesthesia or lumbar puncture in thrombocytopenic individualsBritish Journal of Haematology
Anasthesiologie Intensivmedizin Notfallmedizin Schmerztherapie
The network of regional anesthesia scientific working group. Regional anesthesia of DGAI and the BDA
Anasthesiologie Intensivmedizin Notfallmedizin Schmerztherapie, 44():
AnaesthesistPeripartum cardiomyopathy. Interdisciplinary challengeAnaesthesist
Anasthesiologie & Intensivmedizin
Incidence of infectious and neurological complications after thoracic and lumbar epidural catheter placement in a secondary care hospital in Germany
Anasthesiologie & Intensivmedizin, 54():
Journal of AnesthesiaUnilateral sensorimotor deficit caused by delayed lumbar epidural hematoma in a parturient after cesarean section under epidural anesthesiaJournal of Anesthesia
Revue NeurologiqueParaplegia following combined spinal-epidural anesthesia in a patient with an undiagnosed ependymomaRevue Neurologique
European Journal of Anaesthesiology (EJA)Adding regional analgesia to general anaesthesia: increase of risk or improved outcome?European Journal of Anaesthesiology (EJA)
AnesthesiologyThink about Room AirAnesthesiology
AnesthesiologyParturients Expect Safe and Clean Regional AnesthesiaAnesthesiology
AnesthesiologyParturients Expect Safe and Clean Regional AnesthesiaAnesthesiology
AnesthesiologyDroperidol-induced Proarrhythmia: The Beginning of an Answer?Anesthesiology
Current Opinion in AnesthesiologyNeurological complications following central neuraxial blockades in obstetricsCurrent Opinion in Anesthesiology
Current Opinion in AnesthesiologyPresent and emerging strategies for reducing anesthesia-related maternal morbidity and mortalityCurrent Opinion in Anesthesiology
The Journal of Perinatal & Neonatal NursingComplications in Obstetric Anesthesia: Nursing's Role to Anticipate, Recognize, and RespondThe Journal of Perinatal & Neonatal Nursing
Supplemental Digital Content
© 2006 American Society of Anesthesiologists, Inc.
Publication of an advertisement in Anesthesiology Online does not constitute endorsement by the American Society of Anesthesiologists, Inc. or Lippincott Williams & Wilkins, Inc. of the product or service being advertised.