Incidence of Epidural Hematoma, Infection, and Neurologic Injury in Obstetric Patients with Epidural Analgesia/Anesthesia - PowerPoint PPT Presentation

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Incidence of Epidural Hematoma, Infection, and Neurologic Injury in Obstetric Patients with Epidural Analgesia/Anesthesia

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Title: Incidence of Epidural Hematoma, Infection, and Neurologic Injury in Obstetric Patients with Epidural Analgesia/Anesthesia


1
Incidence of Epidural Hematoma, Infection, and
Neurologic Injury in Obstetric Patients with
Epidural Analgesia/Anesthesia
  • ? ??

2
  • Of the 4 million annual births in the USA, 2.4
    million involve epidural analgesia.
  • Severe adverse events
  • -rare but important in young women
  • Data for superficial and deep infections,
    hematoma, and transient and permanent neurologic
    injury from studies reporting adverse events with
    obstetric epidural analgesia.
  • Incidence as individual risk for a
    woman,numberof events per million women, and
    percentage incidence.
  • A total of 1.37 million women received an
    epidural for childbirth, reported in 27 articles.

3
  • Most information (85 of women) was in
  • larger(gt 10,000 women) studies published
    after 1990.
  • Risk estimates as follows
  • - epidural hematoma, 1 in 168,000
  • deep epidural infection 1 in 145,000
  • persistent neurologic injury, 1 in 240,000
  • transient neurologic injury, 1 in 6,700
  • Earlier and smaller studies produced
    significantly higher risk estimates for transient
    neurologic plus injury of unknown duation.

4
  • Approximately 60 of women in USA giving birth in
    larger hospitals (gt 1,500 births a year) have
    epidural and this number decreases to 42 in
    smaller hospitals (100-500 birhts)
  • In the United Kingdom, the epidural rate is
    approximately 35 in Canada, it is 45 and in
    France in 1996, it was 51
  • Because of the large number of healthy young
    women having epidurals during labor, even rare
    adverse events are important, especially if they
    are serious- quality of life, economic costs

5
Metarials and method
  • Searched PubMED (from 1966), EMBASE (from
    1980),and MEDILINE (from 1966) to February 2005,
    with no restrictions on language or type of study
  • Five journals ( Anesthesiology, Anesthesia
    Analgesia, British Journal of Anesthesia,
    Anesthesia, and Acta Anaesthesiologica
    Scandinavica) were hand-searched from mid-1990 to
    2005.
  • Reference lists were checked for additional
    studies
  • FIG-1

6
Metarials and method
7
Metarials and method
  • Took definitions of adverse events as described
    by the authors of the individual studies
  • For infections, superficial infections (e.g.,
    skin infections around the catheter site) and
    deep infections (in the epidural space)
  • For neurological injuries, transient (resolved
    within 1yr) and persistent (not resolved within
    1yr)

8
Metarials and method
  • Planned to perform sensitivity analyses for
    larger (gt10,000 women) versus smaller studies and
    for older ( published before 1990) versus recent
    studies.-relative risk calculated.
  • 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
  • percent of women with the complication
  • annual incidence of these events for several
    countries

9
results
  • The 27 articles reported on 1.37 million women
    having an epidural for childbirth
  • The 11 studies with 1.31 million women in all
    each reported on more than 10,000 women (range,
    10,995-506,000)
  • The 16 studies with 1.19 million women were
    published after 1990.
  • The 7 larger post-1990 studies had 1.16 million
    women 85 of the total.

10
Results Epidural Hematoma
11
Results Epidural Infection
  • Only two studies reported on superficial
    infection stating no events

12
Persistent Neurologic Injury
  • None of these was clearly related to epidural
    hematoma or epidural infection

13
Transient Neurologic Injury
  • Definition of neurologic damage were not always
    clear in almost all cases, only symtoms were
    described, without any link between the injury
    and either epidural or childbirth.

14
Transient Neurologic Injury Plus Injury of
Unknown Duration
  • Because it is probable that Injury of Unknown
    Duration were tansient, analyzed them together
    with known transient injuries.

15
Sensitivity analysis
  • Performed sensitivity analysis only for transient
    neurologic injury or injury of unknown duration
    because they 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

16
Sensitivity analysis
  • 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, a 15-fold difference.
  • 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, a 4-fold difference.

17
Discussion
  • Expectation is that modern childbirth is
    relatively safe for mother and baby.
  • Any intervention in childbirth 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
    and eliminate selection bias requires large
    numbers of patients
  • Almost all of the information (85 of women
    studied) was in the larger post-1990 studies

18
Discussion
  • Only 6 epidural hematomas , 11 deep epidural
    infection and 3 persistent neurologic injuries
    were reported? inadequate to produce a robust
    estimate of event rate
  • These event rate 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

19
Discussion
  • Neurologic deficits after childbirth may have
    many causes, and all of these adverse events
    could occur spontaneously or because of
    childbirth.? 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.
  • Other potential weakness
  • -serious adverse events may also be
    underreported.
  • cultural, social, and legal consideration,
    especially relating to epidurals and childbirth,
    might also restrict reporting in the medical
    literature.

20
Discussion
  • Transient and permanent, although time is clear
    important, the seriousness of damage (from skin
    numbness to paraplegia) should also be borne in
    mind.
  • Found no information about risk factors for
    adverse events or information linking events such
    as epidural hematoma of infection to neurologic
    injury? more likely to be found in case reports
  • Finally, results relate only to childbirth.
  • -different result might be expected in older
    patients with epidurals for a short period for
    surgical proedures, or patients with long-term
    epidurals for chronic pain relief.
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