Anesthesiology clinics of North America
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Perhaps the clearest picture of the numbers and types of injuries from regional anesthesia is provided by the ASA Closed Claims Project database. In reviewing these data, it is valuable to keep in mind, of course, that the lack of a denominator makes the calculation of incidence impossible. For the decade of the 1990s, 308 claims were associated with regional anesthesia (versus 642 claims associated with general anesthesia). ⋯ The most common of these (23%) was associated with nerve blocks of the eye (13 retrobulbar, 3 peribulbar), and typically the injury entailed loss of vision. Second in frequency (21%) were pain-management related claims involving, for example, neuraxial opiates or neurolytic blocks. Third in frequency (20%) were nerve injuries associated with neuraxial and peripheral blocks followed by epidural hematomas (13%).
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Watcha and White [51] have made recommendations for antiemetic therapy and prophylaxis based on published peer-reviewed studies. They range from no prophylaxis for patients at low risk to "multimodal" antiemetic therapy for those at the highest risk (Fig. 1) [10]. Recommendations for rescue therapy of breakthrough PONV are also provided. With this approach, it should be possible [figure: see text] to individualize prophylaxis and rescue therapy to achieve an optimal cost-effective management strategy for this uncomfortable postoperative complication.
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This chapter discusses the cases of postoperative blindness reported in the literature and the theories that attempt to explain the mechanisms involved. Although uncommon, alterations in vision and blindness after anesthesia for major surgical procedures, particularly cardiopulmonary bypass or spine surgery, are well documented, with an incidence varying between 0.05% and 1%. ⋯ However, the large number of case reports over many years has provided some significant information. Although sustained compression of the eye is an important cause, postoperative visual loss may also occur, in an unrelated manner, because of ischemic optic neuropathy, central retinal artery or vein occlusion, or cortical blindness.
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Epidural and spinal anesthesia enjoy wide usage in modern practice, and each can provide reliable and safe anesthesia. Although the techniques appear to the casual observer to require relatively straightforward technical skill, both are fraught with myriad hazards and potential complications. It is the familiarity with and the understanding of these complications that makes for safe and professional practice of these techniques.