Epidural Complications   Since the introduction of the Epidural in the mid 1930's, laboring mothers have been given epidurals on a more frequent basis. Throughout this time there has been numerous studies indicating problems with the use of epidurals. There are many complications that can occur during an epidural, some of which are mild but some are extremely serious and can even cause cardiac arrest and death. The reasons for which these complications arise vary depending on the drugs used, dose administered, and concentration of certain drugs; Furthermore, without careful monitoring, a small complication can quickly become serious and problematic for the mother and child. One must take a serious look at these complications and know them before an epidural is given. The patient should question the doctor on what is given during an epidural and what is to be expected. To often the doctor doesn't inform the patient on all aspects of the epidural, afraid that it might scare the mother away from having an epidural. If this is the case, he is not doing his duty on informing the patient in order for her to make an informed  decision. In 1975 Usubiaga reviewed 750,000 epidural anesthetics and found an incidence of severe neurological complications of 1:11,000. In 1980 case reports by Reisner and Ravindran described neurologic deficits following intrathecal  2-chloroprocaine. It was found that accidental subarachnoid injection of large doses of 2-chloroprocaine were the cause. The complications associated with an epidural are as follows:   Seizures Toxicity (CNS & CVS) Fetal Bradycardia Fetal Acidosis Total Spinal Paralysis Cardiac Arrest Back problems Bacterial Meningitis Epidural Abscess Lumbosacral Nerve Injury Femoral Nerve Injury Peroneal Nerve Damage Epidural Nerve Puncture Cardiac Arrhythmia Maternal Hypertension Inadvertent Dural Puncture Postdural Puncture Headache Urinary Retention Nausea and Vomiting Drug Overdose Hypotension Respiratory Depression Hypoxia There are also complications that can effect the baby. Theses complications will not only harm the mother but can potentially harm the baby as well. Studies have shown that epidural anesthesia effects baby's. Although there aren't many studies and more have to be conducted, potential problems still exist, and until further studies are concluded, the mother should be aware of all potential risks to their child. The effects of epidural anesthesia on newborns are as follows   lowered neurobehavioral scores on newborn Decrease in muscle tone and strength Respiratory depression in baby Fetal Malpositioning Fetal heart rate variability Increase need for forceps, vacuum and cesarean deliveries and episiotomies  Most of these complications have been discovered only after serious problems occurred due to the drugs used and technique. In the 1970's anesthesiologists used the drug Bupivacaine, the most common anesthetic used for epidurals. This drug was given in high concentrations, and when it was mistakenly injected into the women's veins, instead of the epidural space, this would result in cardiac arrest causing death. This led to a ban of this concentration in obstetrics, but not a ban on the drug. Seizures Seizures most often occur when concentrations of local anesthetic reach toxic levels in the Brain. Immediate actions must be taken to stop the seizure that could potentially result in fetal and Maternal Hypoxia, acidosis and death. This occurs when high doses of anesthetic are given in highly vascular areas. Prior to convulsions, the patient will show signs such as slurred speech or ringing in the ears. This is why close monitoring and verbal contact is required. Toxicity (CNS and CVS) Toxic effects of local anesthetic drugs occur when excessive blood levels occur. This is due to: Accidental rapid Intravenous injection. Rapid absorption, such as from a very vascular site.  Absolute Overdose if the dose used is excessive Toxic effects due to anesthetic overdose primarily effect the Central Nervous System and Cardiovascular System. The nervous system is more susceptible to toxicity; Therefore, will be the first to show signs followed by the cardiovascular. CNS Toxicity Signs of CNS Toxicity come in stages, the first being mild and the second severe. Mild Toxicity: Light-headedness Dizziness Tinnitus Circumoral numbness Abnormal taste Confusion Drowsiness Before any severe toxicity occurs the anesthesiologist should talk to the patient and ask how they feel. Any suggestion of confusion should alert the doctor of toxicity and injection should stop. Sever Toxicity: Tonic-clonic convulsions los of consciousness Coma Respiratory depression Respiratory arrest Depending on the drug and dose given the patient may go from awake to convulsion in a very short time.   CVS Toxicity Signs of CVS Toxicity also come in two stages mild and severe. Mild Toxicity: Tachycardia and Rise in blood pressure. This will occur if the is adrenaline in the local anesthetic. Bradycardia with hypotention (low blood pressure). This will occur if the is no adrenaline in the anesthetic. Severe Toxicity: 4 to 7 times the dose needs to be injected before cardiovascular collapse occurs. Collapse due to depressant effect of anesthesia acting directly on the myocardium. Bupivacaine in considered to be the most cardiotoxic Severe and intractable arrhymthmias can occur with accidental IV injection Toxicity of local anesthetic is due to the speed and rise of blood concentration. Therefore a rapid injection od a small volume may cause toxicity.   Essential Precautions to prevent Toxicity Secure intravenous access before any dose of anesthetic is ever injected. Treatment of Toxocity Treatment of toxicity is based on the principal of Airway, Breathing, Circulation, and Drugs. Airway must be clear and adequate and oxygen given Breathing must noticeable, Patient must be ventilated with self inflating bag if not breathing properly.  If circulation is inadequate, the patient must be treated with IV fluids Drugs to stop the seizure such as Diazapam 0.2-0.4mg/kg intravenously or Thiopentone 1-4mg/kg intravenously will be given to control seizures. They may be repeated after 10 minutes. The patient will be observed closely following a toxicity episode. Fetal Bradycardia This occurs when the fetal heart rate goes below 100 for a length of time. This condition can become serious of prolonged. Fetal Acidosis Too much acid in the blood and body. This is a distinctly abnormal condition. It results from the accumulation of acid or the depletion of alkaline reserves. The pH of the acidotic body measures below normal. Acidosis is associated with some forms of diabetes, lung disease, and severe kidney disease. For a person with diabetes, this can lead to diabetic ketoacidosis. The opposite of acidosis is alkalosis in which there is too high a pH due to excess base or insufficient acid in the body. Total Spinal This condition occurs when the anesthetic goes to high and the patient loses sensation up to the face. The patient will sometimes complain that she cannot feel herself breathing, Reassurance must be given in order for the mother to feel calm. Oxygen may be given at this point to help with breathing. Paralysis Though very rare, paralysis may occur if mistakes are made and the procedure is not performed properly.  Cardiac Arrest This can occur as a result of Toxicity as mentioned above. It is especially true with the use of Bupivacaine dose of .75% concentration. Back Problems There are many studies that show woman with post epidural back problems for years following the epidural Bacterial Meningitis Though very rare, Epidural infection can occur. It is most often caused by the instruments used. Therefore, meticulous aseptic sterile conditions have to be used when administering epidural anesthesia, especially outside the operating room Epidural Abscess Sings of Epidural abscess are, lower limb weakness (4 day interval), and paraplegia (24 hours after weakness) Early diagnosis and aggressive antibiotic treatment will prevent the progression of epidural abscess formation and the necessity for surgical drainage. Lumbosacral Nerve Injury Sings of lumbosacral nerve injury include: Paralysis of the dorsiflexors of the ankle with footdrop Hypalgesia over the lateral aspect of the calf and foot Slight weakness of the quadriceps (L4) Slight weakness of the hip adductors (L4, L5) The lesion is usually unilateral, recovery may take months and may be incomplete Femoral Nerve Damage Sings of Femoral nerve damage include: Quadriceps paralysis Loss of patellar reflex Hypalgesia over the front of the thigh and medial aspect of the calf Numbness of the anteriolateral part of one thigh Femoral nerve injury is usually believed to be caused by prolonged position in the lithotomy stirrups leading to partial eschemia from kinking as the nerve passes under the inguinal ligament. Peroneal Nerve Damage Sings of peroneal nerve damage include: Foot Drop Hypoesthesia over lateral aspect of lower leg Epidural Nerve Puncture Inadvertent intravascular injection of local anesthetic may occur at any time during continuous epidural anesthesia. To alleviate this test doses of small amounts of local anesthetic must be given before any therapeutic epidural dose. Negative aspiration of the catheter is not assurance that the tip is intravascular. The mother must be watched closely for at least 3 to 5 minutes before reinfection. Inject only 5 ml increments of the drug. Cardiac Arrhythmia Arrhythmias are caused by a disruption of the normal functioning of the electrical conduction system of the heart. Normally, the chambers of the heart (atria and ventricles) contract in a coordinated manner. The signal to contract is an electrical impulse that begins in the sinoatrial node (sinus node, SA node). It is conducted through the atria and stimulates them to contract. The impulse passes through the atrioventricular node (AV node), then travels through the ventricles and stimulates them to contract. Problems can occur anywhere along the conduction system, causing various arrhythmias. Problems can also occur in the heart muscle itself, causing it to respond differently to the signal to contract, also causing arrhythmias, or causing the ventricles to contract independently of the normal conduction system. Arrhythmias include tachycardias (heartbeat too fast), bradycardias (heartbeat too slow) and "true" arrhythmias (disturbed rhythm). Arrhythmias are classified as lethal if they cause a severe decrease in the pumping function of the heart. When the pumping function is severely decreased for more than a few seconds, blood circulation is essentially stopped, and organ damage (such as brain damage) may occur within a few minutes. Lethal arrhythmias include ventricular fibrillation, also ventricular tachycardia that is rapid and sustained, or pulseless, and may include sustained episodes of other arrhythmias. Maternal Hypertention Maternal hypertention is the increase in blood pressure in high levels. This can cause problems for the mother and the fetus if not treated.