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Risk of a Severe Neurological Complication After Regional Anesthesia Should Be Individualized

Section Editor(s): Saidman, LawrenceBrull, Richard MD, FRCPC; McCartney, Colin J.L. MBChB, FRCA, FFARCSI, FRCPC; Chan, Vincent W.S. MD, FRCPC; El-Beheiry, Hossam MBBCh, PhD, FRCPC

doi: 10.1213/01.ane.0000270268.80141.95
Letters to the Editor: Letters & Announcements
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Department of Anesthesia and Pain Management; Toronto Western Hospital; University Health Network; University of Toronto; Toronto, ON; Canada; richard.brull@uhn.on.ca

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In Response:

Dr. Fowler (1) clearly points out the inherent limitations, including heterogeneity and underreporting, in our recently published review of neurological complications after regional anesthesia (2). Our manuscript was not meant to be a “one size fits all” definitive list of complication rates; rather, the intent was to consolidate and illustrate the existing data, however flawed, in summary estimates and confidence intervals that may help practitioners address the frequency of severe neurological complications during discussions of risk associated with regional anesthesia. We purposely excluded epidural hematoma and abscess from our review because these complications have been examined in detail elsewhere (3–6) and are intimately associated with unique risk factors, such as thromboprophylaxis and immunodeficiency. We disagree with Fowler's opinion that temporary neuropathy is of questionable significance during the informed consent process because neuropathy, however transient, may cause considerable distress to patients (and their practitioners) as well as prompt costly consultation and invasive investigation.

As a matter of course, complication rates should ideally be “tailored” to the individual patient according to each risk factor that he or she presents. However, the data that would enable us to calculate the true incidence of severe neurological complications associated with regional anesthesia are currently unavailable. Large-scale,multi-institutional, prospective projects, such as the 3rd National Audit of Major Complications of Spinal and Epidural Anaesthesia currently underway in the United Kingdom (7), will hopefully bring us closer to the elusive grand denominator that undermines calculations of incidence for such rare events. Until then, we must continue to analyze, scrutinize, but importantly, use all of the existing data in the best way we can. A concise, user-friendly, consolidated resource for estimating the risk of neurological complications after regional anesthesia seemed to us like a good place to start.

Richard Brull, MD, FRCPC

Colin J.L. McCartney, MBChB, FRCA, FFARCSI, FRCPC

Vincent W.S. Chan, MD, FRCPC

Hossam El-Beheiry, MBBCh, PhD, FRCPC

Department of Anesthesia and Pain Management

Toronto Western Hospital

University Health Network

University of Toronto

Toronto, ON

Canada

richard.brull@uhn.on.ca

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REFERENCES

1. Fowler SJ. Risk of a severe neurological complication after regional anesthesia should be individualized. Anesth Analg 2007;105:880–1
2. Brull R, McCartney CJ, Chan VW, El Beheiry H. Neurological complications after regional anesthesia: contemporary estimates of risk. Anesth Analg 2007;104:965–74
3. Kindler CH, Seeberger MD, Staender SE. Epidural abscess complicating epidural anesthesia and analgesia. An analysis of the literature. Acta Anaesthesiol Scand 1998;42:614–20
4. Tryba M. [Epidural regional anesthesia and low molecular heparin: Pro]. Anasthesiol Intensivmed Notfallmed Schmerzther 1993;28:179–81
5. Vandermeulen EP, Van Aken H, Vermylen J. Anticoagulants and spinal-epidural anesthesia. Anesth Analg 1994;79:1165–77
6. Wang LP, Hauerberg J, Schmidt JF. Incidence of spinal epidural abscess after epidural analgesia: a national 1-year survey. Anesthesiology 1999;91:1928–36
7. The 3rd National Anaesthesia Audit Major Complications of Spinal and Epidural Anaesthesia. The Royal College of Anaesthetists Bulletin 2006;39:1980
© 2007 International Anesthesia Research Society