Puerperal ventral epidural hematoma after epidural labor analgesia

Serious complications in obstetric anesthesia are a rare occurrence. High neuraxial block, respiratory arrest in labor and delivery, and an unrecognized spinal catheter are among the most frequently reported serious complications. A serious complication occurs in approximately 1:3 000 obstetric patients. Neuraxial hematoma after obstetric epidural analgesia or anesthesia is extremely rare.We present a case of a puerperal spinal epidural hematoma following epidural labor analgesia. The patient presented with foot drop, which resolved after conservative treatment. We reviewed the epidemiology, clinical manifestations and treatment options for this rare complication.     

Epidural abscess after epidural catheter for pain release during pancreatitis

BACKGROUND: Despite knowledge about compromised host defence in the course of diabetes mellitus and pancreatitis, epidural analgesia (EA) is recommended for pain management during pancreatitis. CASE REPORT: We present the case of a diabetic patient with pancreatitis who developed an epidural abscess after 3 days with an epidural catheter. Natural killer and T-helper cell counts were distinctively reduced in the absence of HIV serology. Furthermore, a synthesis failure of the liver was observed and evidenced by low cholinesterase, low whole protein fraction and low antithrombin III in the peripheral blood. CONCLUSION: We suggest that the combination of pancreatitis, diabetes and compromised immunity might be a contraindication to epidural analgesia.     

Survey of epidural analgesia management in general intensive care units in England

BACKGROUND: The management of epidural analgesia is controversial. Many intensive care unit (ICU) patients may benefit from this form of analgesia but have one or more contraindications to its use. Sepsis, coagulopathy, insertion in a sedated, ventilated patient, and lack of consent are common problems in ICU patients. Little has been published to help guide practice in this area. I wished to establish the current practice of the management of epidural analgesia in general ICUs in England when relative or absolute contraindications occur, in order to determine the current standard of care for placement and use of epidural analgesia in ICU patients. METHODS: A postal questionnaire survey of the management of epidural analgesia in critically ill patients was sent to the named clinical director of all (216) general ICUs in England. RESULTS: Responses were received from 159 (75%) units: 89% of responding units use epidural analgesia but only 51(32%) have a written policy covering its use. Anesthetists or intensivists with an anesthetic background sited all epidural catheters; 68% of units would not site an epidural in a patient with positive blood cultures; but only 52% considered culture negative sepsis (systemic signs of sepsis with no organism isolated) to be a contraindication. Neither lack of consent nor the need for anticoagulation after the catheter had been sited were considered contraindications to inserting an epidural catheter by the majority of respondents. Although 71% of the units would remove an epidural catheter if a patient developed positive blood cultures after it had been sited, the majority of the ICUs did not consider culture negative sepsis and the need for anticoagulation contraindications to maintain a previously sited epidural. CONCLUSIONS: Practice varied considerably with little consensus. Although all the respondents use epidural analgesia in critically ill patients, the indications and contraindications to epidural analgesia remain controversial, and further research is required to help define the role of epidural analgesia in this high-risk group.     

The effect of epidural analgesia on postoperative outcome after colorectal surgery

OBJECTIVE: The aim of this review was to determine the effects of epidural analgesia as it relates to outcome after colorectal surgery. METHOD: We searched and reviewed studies that included colorectal surgery and epidural method of analgesia listed on the Pubmed, Medline, Embase and the Cochrane library database. RESULTS: The majority of data demonstrate a superior effect of epidural analgesia on pain control after colorectal surgery. Well designed randomized controlled trials (RCT's) have also shown that epidural analgesia reduces the duration of ileus after colorectal surgery. Limited data suggest the additional benefit may be minimal after laparoscopic surgery or when epidural analgesia is used as part of a multimodal regime. Data does not convincingly show either a clear harmful or beneficial effect of epidural analgesia on rates of anastomotic leakage. Epidural analgesia may have beneficial effects on postoperative lung function, however due to low numbers, the effects on cardiovascular and thromboembolic complications are indeterminate. Length of hospital stay has not been shown to be shortened by sole use of an epidural and, although epidural analgesia may be apparently more costly, alternatives may incur higher indirect costs and decreased patient satisfaction. CONCLUSION: Randomized controlled trials have shown a benefit for epidurals on postoperative pain relief, and ileus, and possibly respiratory complications. There is no proven benefit with regard to length of stay. There are a number of unresolved issues which further focussed RCT's may help clarify such as effects of epidural on complication rates after colorectal surgery.     

Spinal epidural abscess--a rare complication after epidural analgesia for labour and delivery

We report a case of spinal epidural abscess formation aftershort-term epidural catheter placement for analgesia duringlabour and delivery. The patient was previously healthy anddid not have any predisposing factors. Increasing back painwas the only complaint. A contrast-enhanced CT study on day5 was inconclusive. Magnetic resonance imaging was performedand showed a large triangular-shaped abscess with adjacent inflammationof the paravertebral muscles. One day later, the patient developeda sensory deficit in the left lower limb. The neurological deficitcompletely resolved after surgical decompression and debridement,which was followed by antibiotic treatment. Br J Anaesth 2004; 92: 896–8     

Spinal epidural hematoma. Report of a case and review of the literature

We report the case of a thoracic epidural hematoma at the T7-T9 level which occurred after placement of spinal epidural catheter for continuous anaesthesia in acute pancreatitis. The male patient felt a sudden back pain after six days of successful analgesia and became paraplegic 24 hours afterwards. An emergency laminectomy and removal of the hematoma were performed; however, the patient recovered only incompletely.We discuss the clinical signs and symptoms of spinal epidural hematoma as well as its diagnostics and therapy. The controversial views from the literature concernings its etiology are critically reviewed.     

Long-term outcome after neurosurgically treated spinal epidural abscess following epidural analgesia

BACKGROUND: A recent investigation demonstrated a high incidence of epidural abscess secondary to epidural catheterization and a 50% frequency of neurologic deficits. We studied short- and long-term neurologic outcome in patients operated for spinal epidural abscess after epidural analgesia. METHODS: Nineteen patients who had undergone neurosurgical decompression and drainage of a spinal epidural abscess during a 5-year period at three neurosurgical departments in East Denmark were identified by manual review of operating lists. RESULTS: Median epidural catheterization time was 8 days (range 3-44). Preoperatively 12 patients suffered from inferior paraparesis, one had irradiating pain from the back, and 6 patients had no neurologic deficits. Postoperatively 2 patients had recovered, but 3 other patients had deteriorated; therefore, 13 patients were discharged with paresis/plegia. Seven patients died during a median follow-up time for all patients of 41.6 months. One patient recovered completely, and one suffered from minor deficits. The remaining patients suffered from paraparesis/plegia or bladder/bowel dysfunction. CONCLUSION: Overall recovery rate for patients with paresis/plegia after epidural abscess was 20%. No patients with paresis/plegia following a thoracic abscess recovered in contrast to a 50% recovery rate for patients with lumbar epidural abscess. The majority of long-term survivors had severe neurologic deficits. Abscess formation contributed to one death.     

Epidural abscess following epidural analgesia in pediatric patients

Epidural abscess following epidural analgesia is an unusual event especially in pediatric patients. Two patients presented with fever and local signs of infection without neurological deficit on day 4 after the initiation of epidural analgesia. Neuro-imaging studies revealed epidural abscess. Both pediatric patients were treated successfully with intravenous antibiotics. One of the patients' initial MRI was normal. However, the symptoms persisted and a followed-up scan revealed epidural abscess. The other patient presented with worsening local indurations over the epidural insertion site and positive blood culture with Hemolytic streptococcus. Our experience suggests that neuro-imaging study should be strongly considered to evaluate pediatric patients with suspicion of epidural abscess.     

Spinal haematoma following epidural analgesia

A patient who developed an epidural haematoma with multifactorial aetiology (bleeding diathesis, ankylosing spondylitis, chronic alcoholism and acute pancreatitis) after epidural analgesia for pain relief is described. Our conclusion is that adequate laboratory screening of blood coagulation, including platelet count, should be carried out in this category of patient before attempted epidural blockade, the risks of which must be weighed against the benefits. The block should be allowed to wear off intermittently and repeated neurological assessment performed if an epidural catheter is used for repeated injections or for a continuous infusion of local anaesthetic. Neuroradiological examination should be carried out promptly if an epidural haematoma is suspected and surgical decompression performed without delay if the diagnosis is confirmed.     

Inserción intrapleural involuntaria de un catéter epidural en cirugía torácica: ¿está fuera de juego la analgesia regional o existe otra salida?

In thoracic surgery, optimized pain control is crucial to prevent dysfunction in cardiorespiratory mechanics. Epidural anesthesia and paravertebral block are the most popular techniques for analgesia. Unintended intrapleural insertion of an epidural catheter is a rare complication.Our report presents a case of a patient submitted to pulmonary tumor resection by video-assisted thoracoscopic surgery. There was difficulty in epidural insertion related to patient's obesity, but after general anesthesia induction, no additional intravenous analgesia was needed after epidural injection. Surgery required conversion to thoracotomy, with intrapleural identification of epidural catheter. At the end of surgery, surgeons reoriented catheter to paravertebral space, with leak absence confirmation after local anesthetic injection through the catheter. In postoperative period, pain control was efficient, with no complications.It was a successful case that shows that when we find unexpected complications, we can look for alternative solutions to give our patient the best treatment.     

硬膜外超前镇痛对上腹部手术病人应激反应的影响

目的 比较硬膜外超前镇痛和术后硬膜外镇痛对上腹部手术病人应激反应的影响.方法 择期全麻下拟行上腹部手术的病人30例,ASA Ⅰ或Ⅱ级,随机分为2组(n=15):术后硬膜外镇痛组(C组)和硬膜外超前镇痛组(P组).于T_(10,11)间隙行硬膜外穿刺并置管.P组切皮前20 min时硬膜外注射0.5 μg/ml舒芬太尼+0.15%罗哌卡因混合液15 ml,30 min后接镇痛4泵,以5 ml/h的速率硬膜外输注250 ml.C组病人术后硬膜外注射0.5μg/ml舒芬太尼+0.15%罗哌卡因混合液15 ml,30 min后接镇痛泵,以5 ml/h的速率硬膜外输注250 ml.于硬膜外穿刺前(T_0),术后2 h(T_1)和18 h(T_2)时,采集静脉血样6 ml,测定血浆促肾上腺皮质激素(ACTH)浓度和血清皮质醇(Cor)、C反应蛋白(CRP)的浓度.结果 与T0时比较,两组,T1和T2时血清Cor、CRP的浓度和血浆ACTH浓度均升高(P<0.01);与C组比较,P组T1和T2时血清Cor、CRP的浓度和血浆ACTH浓度均降低(P<0.05).结论 与术后硬膜外镇痛相比,硬膜外超前镇痛可更好地抑制上腹部手术病人术后应激反应.     

Anterior ischemic optic neuropathy after emergency caesarean section under epidural anesthesia

We report a case of non arteritic anterior ischemic optic neuropathy following caesarean delivery in a patient who had epidural analgesia. There was doubt as to whether it was subdural. The patient underwent caesarean section because of second stage non-progression of labor. We discuss the possible etiology of this unpleasant complication.     

硬膜外分娩镇痛对分娩方式的影响

目的 评价硬膜外分娩镇痛对分娩方式的影响.方法 初产妇400例,ASA Ⅰ或Ⅱ级,足月、单胎、头位,无妊娠并发症及硬膜外麻醉禁忌证.分为硬膜外镇痛组和非镇痛组(n=200).硬膜外镇痛组宫口开至3 cm时,采用0.1%罗哌卡因混合0.5 μg/ml舒芬太尼行硬膜外镇痛,宫口开全后停止镇痛.记录镇痛前和镇痛15 min时VAS评分;评价运动阻滞程度;记录分娩方式、第一产程、第二产程、新生儿出生后1、5 min时Apgar评分和新生儿体重;记录镇痛过程中不良反应的发生情况.结果 硬膜外镇痛组镇痛15 min时VAS评分由(8.3±0.8)分降至(1.6±1.1)分(P＜0.05).与非镇痛组比较,硬膜外镇痛组顺产率和阴道器械助产率升高,剖宫产率降低,第一产程和第二产程延长(P＜0.05).2组新生儿出生后1、5 min时Apgar评分和新生儿体重比较差异无统计学意义(P＜0.05).硬膜外镇痛组下肢运动阻滞发生率为0.5%,下肢麻木发生率为9.0%,恶心呕吐发生率为1.5%.结论 硬膜外分娩镇痛可降低剖宫产率,提高自然分娩率.     

Techniques of epidural block

Epidural blocks can be performed at any level from the high cervical spine down to the sacral hiatus. A lumbar epidural can provide surgical anaesthesia and postoperative analgesia for sub-umbilical surgery, whereas a thoracic epidural will provide effective analgesia but not anaesthesia for thoracic and upper abdominal surgery. A single-shot bolus has a duration of 2-4 hours, using a long-acting local anaesthetic, but in the majority of cases prolonged postoperative analgesia is achieved by inserting an epidural catheter and infusing a dilute local anaesthetic and opioid drug combination. Although a useful regional anaesthetic technique with significant patient benefits, an epidural is an invasive procedure, can be technically difficult, and has the potential to cause serious adverse events (direct needle trauma to the spinal cord or the spinal nerve roots, vertebral canal haematoma and meningitis or epidural abscess) if not done to a high standard and managed appropriately. Epidural and caudal blockade have a number of synonyms, which can be confusing. The terms ‘epidural’ (extradural, peridural) and ‘caudal’ (sacral epidural) are used throughout this article.     

Regional analgesia in early active labour: combined spinal epidural vs. epidural

We randomly allocated 93 women in early active labour and requesting epidural analgesia to receive either epidural ( n  = 48) or combined spinal–epidural analgesia ( n  = 45). For epidural analgesia 15 ml of bupivacaine 0.1% with 75 μg of fentanyl were injected into the epidural space. For combined spinal–epidural analgesia 1 ml of bupivacaine 0.25% with 25 μg of fentanyl were injected into the subarachnoid space. For both groups subsequent top-ups of 10 ml of bupivacaine 0.1% with fentanyl 20 μg were given using a lightweight patient-controlled epidural analgesia (PCEA) pump with a lockout time of 30 min. We assessed analgesia and the degree of motor blockade and found no significant differences in pain or maternal satisfaction scores between the two groups. The time to first top-up was significantly longer in the epidural group than in the CSE group (p = 0.01). The combined spinal–epidural group had significantly greater motor blockade at 30 min than the epidural group (p = 0.01), but there was no difference after this. The PCEA machine failed completely twice and temporarily many times. We conclude that the combined spinal–epidural technique confers no advantages in early active labour. Also, a lightweight PCEA pump needs to be more reliable before we can recommend its use.     

Risk factors for failure to extend labor epidural analgesia to epidural anesthesia for Cesarean section

AIM: To identify parturients at risk of inability to extend labor epidural analgesia in whom alternative methods of anesthesia should be considered for Cesarean section (CS). METHODS: For 6 months, we prospectively studied women undergoing CS with a functioning epidural catheter in place from the delivery ward. All parturients received the same epidural protocol: bolus of bupivacaine 0.1% and fentanyl, followed by bupivacaine 0.1% and fentanyl (2 microg/ml) 10-15 ml/h and an additional 5 ml of bupivacaine 0.125% as top-up according to patient request. Sixteen milliliters of lidocaine 2%, 1 ml of bicarbonate and 100 microg of fentanyl were given for CS. Failed epidural analgesia was defined as the need to convert to general anesthesia. RESULTS: Of the 101 parturients studied, 20 (19.8%) required conversion to general anesthesia. In univariate analysis, the likelihood of failed epidural anesthesia was inversely correlated with parturient age (P = 0.014) and directly correlated with pre-pregnancy weight (P = 0.019), weight at the end of pregnancy (P = 0.003), body mass index at the end of pregnancy (P = 0.0004), gestational week (P = 0.008), number of top-ups (P = 0.0004) and visual analog scale (VAS) score 2 h before CS (P = 0.03). In multivariate analysis, the number of top-ups in the delivery ward was the best predictor of epidural anesthesia failure (odds ratio, 4.39; P = 0.005). CONCLUSION: Younger, more obese parturients at a higher gestational week, requiring more top-ups during labor and having a higher VAS score in the 2 h before CS are at risk for inability to extend labor epidural analgesia to epidural anesthesia for CS.     

Lateral cervical epidural catheter placement using nerve stimulation for continuous unilateral upper extremity analgesia following a failed continuous peripheral nerve block

This case report describes the application of electrical stimulation (Tsui test) to confirm placement of a cervical epidural catheter for postoperative pain management in a patient with a failed brachial plexus block who underwent upper extremity surgery. An epidural catheter was easily advanced under nerve stimulation guidance to the surgical dermatome C4 level without any resistance from the C7-T1 level. Successful analgesia was achieved with a bolus of 2 mg ml(-1) ropivacaine 2 ml and fentanyl 20 microg, followed by a continuous infusion of 2 mg ml(-1) ropivacaine with 2 microg ml(-1) of fentanyl at a rate of 2 ml h(-1). This case reminds the clinician that cervical epidural analgesia may serve as an alternative to a difficult continuous peripheral nerve block. Electrical stimulation may also help to confirm cervical epidural catheter placement at the appropriate dermatome to provide effective analgesia with minimal side-effects.     

Risk factors for failure to extend labor epidural analgesia to epidural anesthesia for Cesarean section

OBJECTIVE: To identify parturients at risk of inability to extend labor epidural analgesia in whom alternative methods of anesthesia should be considered for Cesarean section (CS). METHODS: For 6 months, we prospectively studied women undergoing a CS with a functioning epidural catheter in place from the delivery ward. All parturients received the same epidural protocol: bolus of bupivacaine 0.1% and fentanyl, then bupivacaine 0.1% and fentanyl (2 microg/ml) 10-15 ml/h and an additional 5 ml of bupivacaine 0.125% top-ups according to patient request. Sixteen millilitres of lidocaine 2%, 1 ml of bicarbonate, and 100 microg of fentanyl were given for CS. Failed epidural analgesia was defined as the need to convert to general anesthesia. RESULTS: Of the 101 parturients studied, 20 (19.8%) required conversion to general anesthesia. In univariate analysis, the likelihood of failed epidural anesthesia was inversely correlated with parturient's age (P = 0.014) and directly correlated with pre-pregnancy weight (P = 0.019), weight at the end of pregnancy (P = 0.003), body mass index (BMI) at the end of pregnancy (P = 0.0004), gestational week (P = 0.008), number of top-ups (P = 0.0004) and visual analog scale (VAS) 2 h before CS (P = 0.03). In multivariate analysis, the number of top-ups in the delivery ward was the best predictor of epidural anesthesia failure (odds ratio 4.39, P = 0.005). CONCLUSION: Younger, more obese parturients at a higher gestational week, requiring more top-ups during labor, having a higher VAS in the 2 h before CS are at risk of inability to extend labor epidural analgesia to epidural anesthesia for CS.     

Continuous versus intermittent epidural analgesia

A randomised study of 381 women was carried out to compare the obstetric outcome after epidural analgesia maintained by an intermittent top-up regimen or with a continuous infusion. The two groups were well matched with respect to age, parity, mode of onset of labour and indication for epidural. Maintenance of epidural analgesia by continuous infusion resulted in a significantly decreased need for top-up doses. A reduction in the incidence of hypotension, cardiotocographic evidence of intrapartum fetal hypoxia and Caesarean section was associated with this. It is concluded that the maintenance of epidural analgesia by continuous infusion is a safe and reliable method and may be more advantageous and less labour intensive than the traditional intermittent regimen.     

Programmed intermittent epidural bolus vs. patient-controlled epidural analgesia for maintenance of labour analgesia: a two-centre,double-blind,randomised study†

The programmed intermittent epidural bolus technique has shown superiority to continuous epidural infusion techniques, with or without patient-controlled epidural analgesia for pain relief, reduced motor block and patient satisfaction. Many institutions still use patient-controlled epidural analgesia without a background infusion, and a comparative study between programmed intermittent epidural bolus and patient-controlled epidural analgesia without a background infusion has not yet been performed. We performed a randomised, two-centre, double-blind, controlled trial of these two techniques. The primary outcome was the incidence of breakthrough pain requiring a top-up dose by an anaesthetist. Secondary outcomes included: motor block; pain scores; patient satisfaction; local anaesthetic consumption; and obstetric and neonatal outcomes. We recruited 130 nulliparous women who received initial spinal analgesia, and then epidural analgesia was initiated and maintained with either programmed intermittent epidural bolus or patient-controlled epidural analgesia using ropivacaine 0.12% with sufentanil 0.75 µg·ml^-1. The programmed intermittent epidural bolus group had a programmed bolus of 10 ml every hour, with on-demand patient-controlled epidural analgesia boluses of 5 ml with a 20 min lockout, and the patient-controlled epidural analgesia group had a 5 ml bolus with a 12 min lockout interval; the potential maximum volume per hour was the same in both groups. The patients in the programmed intermittent epidural bolus group had less frequent breakthrough pain compared with the patient-controlled epidural analgesia group, 7 (10.9%) vs. 38 (62.3%; p < 0.0001), respectively. There was a significant difference in motor block (modified Bromage score ≤ 4) frequency between groups, programmed intermittent epidural bolus group 1 (1.6%) vs. patient-controlled epidural analgesia group 8 (13.1%); p = 0.015. The programmed intermittent epidural bolus group had greater local anaesthetic consumption with fewer patient-controlled epidural analgesia boluses. Patient satisfaction scores and obstetric or neonatal outcomes were not different between groups. In conclusion, we found that a programmed intermittent epidural bolus technique using 10 ml programmed boluses and 5 ml patient-controlled epidural analgesia boluses was superior to a patient-controlled epidural analgesia technique using 5 ml boluses and no background infusion.