American Society of Anesthesiologists 2023 Guidance on Neurologic Complications of Neuraxial Analgesia/Anesthesia in Obstetrics

Both parturients and healthcare providers have fears of neurologic complications associated with neuraxial analgesia/anesthesia, even though the odds are 5- to 10-fold higher for obstetric-related injury.1,2 More than half of parturients want to be informed of anesthetic risks even at a level of 1:10,000 or less.3More than 75% of parturients received neuraxial analgesia/anesthesia, with a cesarean delivery rate of 31% in 2020 in the United States.1 The temporal association between neuraxial analgesia/anesthesia, delivery, and onset of neurologic symptoms means anesthesia providers are often consulted after childbirth. We need to be able to help identify those patients needing immediate imaging and neurologic or surgical evaluation from the more common, less emergent neurologic symptoms.The 2023 American Society of Anesthesiologists (ASA; Schaumburg, Illinois) Statement on Neurologic Complications of Neuraxial Analgesia/Anesthesia in Obstetrics, developed by the Committee on Obstetric Anesthesia, helps all obstetric-related healthcare practitioners.1 The consensus statement provides a basis for informed consent on risks of neuraxial analgesia/anesthesia, shared decision-making, and patient engagement; describes the types and pathophysiology of obstetric and neuraxial analgesia/anesthesia–related deficits; identifies techniques and tools for prompt recognition and evaluation; and identifies recommendations for best practices. Thus, the ASA 2023 statement updates and goes beyond previous recommendations of American Society of Regional Anesthesia and Pain Medicine (Pittsburgh, Pennsylvania), Association of Anaesthetists (London, United Kingdom), and Obstetric Anaesthesists' Association (London, United Kingdom).4,5The ASA statement covers the incidence, types of obstetric and neuraxial analgesia/anesthesia–related neurologic deficits, risk factors, informed consent, intrapartum risk factors, and recognition and management of postdelivery neurologic symptoms with recommended best practices. Most nerve injuries are obstetric related secondary to compression or stretch injury during delivery. Obstetric nonmodifiable risk factors include macrosomia, duration of labor, and mode of delivery. Modifiable risk factors include patient positioning during labor and instrumental delivery.1,2 Neuraxial analgesia/anesthesia modifiable risk factors include using lower concentrations of local anesthetics for labor analgesia and monitoring the degree of motor block.1 Anesthesia-related risk factors include pain and paresthesia on injection and multiple attempts at placement. Use of ultrasound for anticipated difficult neuraxial analgesia/anesthesia may reduce the number of attempts. Neuraxial analgesia/anesthesia neurologic injury in obstetric patients may be as high as 1:83,000, with a higher rate associated with combined spinal epidural relative to epidural.1 Fortunately, neuraxial hematoma and infections are very rare in obstetrics (approximately 1:100,000 to 200,000), but pose the risk of causing life-altering injury.Anesthesia providers are often called after delivery to evaluate patients with lower-extremity neurologic deficits or complaints. The ASA statement describes the assessment of the parturient with neurologic symptoms that includes physical examination, timing, and guidelines for imaging and expert consultations. Distinguishing anesthetic from obstetric causes is timely and necessary. Even though neurologic or neurosurgical consultation may be required, anesthesiologists should be aware of signs and symptoms of nerve injuries affecting the lower extremity. Anesthesia providers should be involved in policies and processes to identify women who have postpartum nerve injuries so that a management plan can be initiated. Monitoring of neurologic symptoms and resolution of anesthetic should be performed in the immediate postpartum period, with prompt communication and escalation of care if symptoms exist. In severe cases, when neuraxial hematoma or infection is suspected, neurosurgical decompression may be needed. Discharge planning should involve safety of ambulation if applicable and a system for follow-up referral and treatment if needed.In conclusion, anesthesia and other obstetric-related providers must be aware of the current methods to help monitor, prevent, and minimize neurologic injuries during anesthesia and childbirth. The 2023 ASA statement is a valuable resource, with information key to helping us partner with our patients, obstetricians, and nurses to improve patient experience and improve outcomes related to neurologic injuries.Support was provided solely from institutional and/or departmental sources.All authors are members of the American Society of Anesthesiologists (Schaumburg, Illinois) Committee on Obstetric Anesthesia. Dr. Zakowski is the current chair.