Regional-Anaesthesie最新文献

We report a patient who was given continuous epidural anesthesia due to painful contractions during delivery of a child after intrauterine fetal death. Placement of the catheter and repeated reinjections were carried out without problems, however, during withdrawal of the catheter it could only be pulled 1-2 cm until there was enormous resistance. An X-ray film showed knotting of the catheter in the epidural space. Firm pulling finally allowed complete withdrawal of the catheter. Insertion of the catheter too far into the epidural space initially must be considered as a possible cause. As this complication rarely occurs, we consider this case worth reporting.

In regional anesthesia the onset of analgesia is usually determined by stimulating the skin with sharp or cold objects: when sensations of sharp pain or cold are lost, all nociceptive afferents are regarded as blocked. Sharp pain and cold are mediated by thin, myelinated axons whereas the majority of nociceptor axons are unmyelinated. In peripheral nerve blocks unmyelinated fibers are blocked first, followed by those mediating sharp pain and cold. In spinal and epidural blocks the levels of anesthesia to sharp pain and cold correspond within 1-2 segments. Although pinprick seems to be a simple test for analgesia, it involves the risk of infection and is disliked by the patient. As the stimulus is spatially discontinuous, coarse testing may simulate analgesia. An ideal stimulus for testing analgesia should be noninvasive, give distinct sensations, not frighten the patient, and allow spatially continuous examination of larger skin areas. A stimulus that meets these conditions is cold applied to the skin by a metal roller (Fig. 1). If the roller is kept at room temperature (20 degrees-24 degrees C), it gives a strong cold sensation when it is slowly rolled (5-10 cm/s) over the warm skin (usually 30 degrees-35 degrees C on the trunk). With this noninvasive device, the levels of anesthesia to cold can be determined rapidly, with high precision, and without frightening the patient.

The effect of a fractional epidural blockade on acute pancreatitis was investigated in a prospective study. PATIENTS AND METHODS. Thoracic (20 patients) or lumbar (six patients) epidural blockade was carried out in 26 patients with severe abdominal conditions comprising sub-ileus in 100%, pancreatic edema indicated by sonography/computer tomography in 57.8%, and necrosis of the pancreas in 34.6%. RESULTS. On average, 3.4 (1-6) injections with single doses of 6-20 ml 0.25% bupivacaine were injected per day. In four patients, morphine (up to 4 mg per 24 h) was added to the local anesthetic. The duration of treatment was between 1 and 15 days. After 10.5% of the injections, the systolic pressure decreased by more than 20%, and after 12.8% of the injections the blood pressure decreased by more than 30%. Hypotension of more than 30% was treated with 0.3 to 0.5 ml theodrenaline (Akrinor) and/or 0.1 to 0.2 mg dihydro-ergotamine (Dihydergot). General analgesics had to be administered in addition on 21.8% of the treatment days and intensive care treatment (artificial ventilation) on 32% of the treatment days. The duration of epidural analgesia varied between 1 and 15 days depending on the intensity of symptoms (pain, ileus). Within 4 days, the enzyme activity of the lipase fell from 8120 to 427 IU, and that of alpha amylase fell from 1401 to 143 IU. In 3 patients laparotomy (for drainage) was performed. An ERCP was carried out in 16 patients. Cardiopulmonary failure necessitated artificial ventilation over a period of 1-15 days in 6 patients; the epidural blockade was continued during the artificial ventilation. Cholecystectomy was carried out as an interval operation in 6 patients. No neurological complications were observed. All patients survived and were discharged from hospital.

We present a 71-year-old male in whom an epidural abscess developed within a short temporal interval after an epidural anesthetic. Due to different locations of the abscess and the site of the epidural puncture, the diagnosis was quite problematic. The initial symptoms consisted of pain in the shoulder-neck region, elevated temperature, and leucocytosis 1 week after the puncture was performed. The further course presented a picture of high spinal paralysis with respiratory insufficiency and massive cardiovascular problems. Magnetic resonance imaging of the cervical spine confirmed the suspected diagnosis of an epidural abscess (Fig. 1). Due to the reduced general condition of the patient, an operation was initially not possible. After the patient's condition had stabilized under antibiotic therapy with penicillin G, vancomycin, and gentamycin, exploration of the abscess area was performed. Histologic studies showed granulomatous tissue resulting from the previous inflammation. During the subsequent course of the disease, the clinical symptoms did not regress significantly. The patient required prolonged mechanical ventilation and died of recurrent bronchopulmonary infections after 5 months of intensive care treatment. The probable pathogenesis of the abscess as well as the diagnostic and therapeutic aspects are discussed in summary.

The availability of very fine-bore, long spinal needles (28/10 Ga) has stimulated a new wave of interest in the technique of combined spinal-epidural anesthesia. The original double-puncture technique has progressed due to special combination needles to the current spinal-needle-through-epidural-needle technique. The availability of adapted Tuohy needles, special combination sets, and long spinal needles indicates a lack of standardization. An appropriate introduction technique via Tuohy needle allows identification of the anatomic landmarks and contributes to successful anesthesia. The spinal component allows a rapid onset and intense analgesia with appropriate muscle relaxation. The epidural catheter allows the administration of agents into the epidural space as well as optimization and prolongation of analgesia in the postoperative phase. Confirming the position of the epidural catheter introduced after spinal anesthesia has been established remains a matter of concern.

In the few case reports of hearing loss following spinal anesthesia, complete recovery of the hearing impairment has always been described. In nine cases with hearing loss following not only spinal anesthesia but also myelography and dural puncture, the hearing of three patients did not recover or only partly returned. Two cases went to court for malpractice. Their suits could be dismissed because it appears likely that this rare complication arises only in persons with a wholly or partially unobliterated aquaeductus cochleae due to loss of perilymphatic fluid into the cerebrospinal space. Hearing loss was seen in eight of nine patients in lower frequencies around 30-40 dB. In six patients there was impairment on both sides. Recovery of normal hearing occurred in six of the nine patients. Transient hearing loss may occur more often than is generally assumed, and the symptom may remain unnoticed when a severe post-dural puncture syndrome with headache, dizziness, and nausea dominates the attention of the patient. Not all cases of hearing loss proved to be fully reversible, but the individual risk for this complication is not predictable. The use of fine-gauge needles may reduce the leakage of cerebrospinal fluid through the dural puncture and thus lower the incidence.

Continuous epidural anesthesia (CEA) is generally accepted as a routine method of regional anesthesia while there has been only limited application of continuous spinal anesthesia (CSA), due mainly to a lack of adequate spinal catheters. With the introduction of a new, ultra-thin spinal catheter (32 G) inserted via a thin puncture needle, some of the complications reported after CSA can be eliminated. We studied CSA versus CEA in lower-extremity operations. METHODS. We evaluated 33 patients in a prospective, randomized study. All were comparable with respect to age, anesthetic risk (ASA II-III), and pre-existing diseases. The only exclusion criterium was the presence of a coagulation disturbance. The CSA group consisted of 17 patients (mean age 75.5 +/- 0.1 year); 26 G puncture needle and 32 G catheter were used. The CEA group consisted of 16 patients (mean age 73.8 +/- 11.0 years); an 18 G puncture needle and 22 G epidural catheter with a stylet were inserted with the loss-of-resistance technique. Both catheters were placed with the patient in a sitting position and left in place for 24 h in order to administer local anesthetics (LA) for postoperative analgesia as required. Hemodynamic parameters-mean arterial pressure (MAP) and heart rate (HR)-were compared in each group at 5-min intervals for 30 min after administration of local anesthetic and at 10-min intervals during the operation. Additionally, the ECG, pulse oximetry, respiratory rate, diuresis, and blood gases were monitored. After placement of the catheter, patients in the CSA group received 1.9 ml (+/- 0.2) bupivacaine HCl 0.5%. Patients in the CEA group received 12.6 ml (+/- 2.5) bupivacaine HCl 0.5%. For statistical evaluation of the data we used mean values, standard deviation (+/-), the Kruscal-Wallis procedure, and Student's t-test for unpaired data. P less than 0.05 was considered significant. RESULTS. The mAPs in the CSA group generally remained lower than those of the CEA group. However, over the course of the operation as well as after repeated injections, the difference between the two groups decreased. Only at 5 min after administration of the initial dose was a statistically significant difference in blood pressures between the two groups observed. A clinically relevant, rapid decrease in blood pressure due to relatively high doses of LA was seen in 1 case in each group. The first reinjection of LA after the initial dose was after 1.9 h in the CSA group (bupivacaine HCl 0.5% 1 +/- 0.3 ml) and after 1.8 h in the CEA group (bupivacaine HCl 0.5% 4.5 +/- 1 ml). The total dose of bupivacaine in the CSA group was 0.18 ml/kg per hour versus 0.8 ml/kg in the CEA group. No post-dural puncture headache was observed in the CSA group. DISCUSSION. The catheter designed for CSA is easy to use, although because of its small diameter a certain manual dexterity is required. In addition, CSA resulted in a more rapid onset of action and more pronounced sensorimotor blockade than did CEA

Acute paraplegia caused by an epidural hematoma developed in a patient following the removal of an epidural catheter. This catheter had been used for 3 days for postoperative pain relief with no apparent complications. Heparin (10,000 units/day) had been infused for thrombosis prophylaxis and was associated with a normal activated partial thromboplastin time (aPTT) for the first two postoperative days. However, test results from blood drawn prior to catheter removal revealed, in retrospect, an unexpected prolongation of the aPTT (75 s) and PT (56%, Quick's method). An epidural hematoma extending from T12 to L4 was evacuated during emergency laminectomy and neurologic deficits resolved completely over the next days. Thus, the removal of an epidural catheter has the potential for inducing formation of an epidural hematoma. Accordingly, it may be safest to leave epidural catheters in place if test results demonstrate a bleeding diathesis or if a potential for bleeding is suspected on clinical grounds.

Since Heinrich Braun added adrenaline to cocaine (and later also to procaine) in 1903 to allow clinical use of this local anesthetic, "limiting dosages" for local anesthetics have been "recommended" with no reference to the technique of administration, on the assumption that adrenaline will lower the toxicity of the local anesthetic used. However, the limiting dosages determined up to now do not take account of important pharmacokinetic and toxicological data: (1) The dependence of blood levels measured on the technique of regional anesthesia and (2) the raised toxicity of a local anesthetic solution containing adrenaline following inadvertent intravascular (intravenous) injection. A maximum dose recommendation that differs according to the technique of local anesthesia is suggested for (A) subcutaneous injection, (B) injection in regions of high absorption, (C) single injection (perineural, e.g. plexus), (D) protracted injection (catheter, combined techniques), (E) injection into vasoactive regions (near to the spinal cord, spinal, epidural, sympathetic). This sequential categorization also underscores the need for selection of appropriate techniques as well as for concomitant monitoring referred to the technique of administration and to the expected and the possible plasma level curve.(ABSTRACT TRUNCATED AT 250 WORDS)