Assessment of main complications of regional anesthesia recorded in an acute pain unit in a tertiary care university hospital: a retrospective cohort

Abstract Background Regional anesthesia has been increasingly used. Despite its low number of complications, they are associated with relevant morbidity. This study aims to evaluate the incidence of complications after neuraxial block and peripheral nerve block. Methods A retrospective cohort study was conducted, and data related to patients submitted to neuraxial block and peripheral nerve block at a tertiary university hospital from January 1, 2011 to December 31, 2017 were analyzed. Results From 10,838 patients referred to Acute Pain Unit, 1093(10.1%) had side effects or complications: 1039 (11.4%) submitted to neuraxial block and 54 (5.2%) to peripheral nerve block. The most common side effects after neuraxial block were sensory (48.5%) or motor deficits (11.8%), nausea or vomiting (17.5%) and pruritus (8.0%); The most common complications: 3 (0.03%) subcutaneous cell tissue hematoma, 3 (0.03%) epidural abscesses and 1 (0.01%) arachnoiditis. 204 of these patients presented sensory or motor deficits at hospital discharge and needed follow-up. Permanent peripheral nerve injury after neuraxial block had an incidence of 7.7:10,000 (0.08%). The most common side effects after peripheral nerve block were sensory deficits (52%) and 21 patients maintained follow-up due to symptoms persistence after hospital discharge. Conclusion Although we found similar incidences of side effects or even lower than those described, major complications after neuraxial block had a higher incidence, particularly epidural abscesses. Despite this, other serious complications, such as spinal hematoma and permanent peripheral nerve injury, are still rare.

Retiro de aguja intradural en la columna toracolumbar. Reporte de un caso / Spinal needle removal in the thoracolumbar spine. Case report

La presencia de elementos extraños dentro del canal raquídeo es infrecuente y no hay claro consenso respecto de su tratamiento. Las publicaciones sobre fragmentos de proyectil de arma de fuego intracanal recomiendan la exéresis de los fragmentos ante la posibilidad de migración, sobre todo, cuando están en una zona próxima al cono medular. Se debería proceder del mismo modo ante una aguja dentro del canal espinal. Presentamos a una paciente con dolor radicular invalidante provocado por un fragmento de aguja dentro del canal espinal luego de una cesárea. Nivel de Evidencia: IV

The presence of foreign elements within the spinal canal is rare and there is no clear consensus regarding its treatment. The publications on intracanal firearm projectile fragments recommend exeresis of the fragments due to the possibility of migration, especially when they are in an area close to the medullary cone. The same procedure should be applied to a needle inside the spinal canal. We present a patient with disabling radicular pain caused by a needle fragment within the spinal canal after cesarean section. Level of Evidence: IV

Cardiac arrest after epidural anesthesia for a esthetic plastic surgery: a case report / Parada cardíaca após peridural para cirurgia plástica estética: relato de caso

Abstract Cardiac arrest during neuraxial anesthesia is a serious adverse event, which may lead to significant neurological damage and death if not treated promptly. The associated mechanisms are neglected respiratory failure, extensive sympathetic block, local anaesthetic toxicity, total spinal block, in addition to the growing awareness of the vagal predominance as a predisposing factor. In the case reported, the patient was 25 years old, ASA I, scheduled for a esthetic lipoplasty. After sedation with midazolam and fentany, epidural anesthesia in interspaces T12-L1 and T2-T3 and catheter insertion into inferior puncture were performed. The patient remained in the supine position for 10 min. Then, she was placed in the prone position, developing asystolic cardiac arrest 20 min after the completion of neuraxial blockade. The medical team immediately placed the patient in the supine position and began cardiopulmonary resuscitation. Spontaneous circulation was achieved after twenty minutes of resuscitation. We discuss in this report the exacerbated vagal response as the main event mechanism. The patient's successful outcome emphasizes the importance of anaesthetic monitoring by anesthesiologists, prompt recognition and treatment of rhythm changes on the electrocardiogram.

Resumo A parada cardíaca durante anestesia neuroaxial é um evento adverso grave, que pode ocasionar sequelas neurológicas importantes e morte se não tratada em tempo hábil. Os mecanismos associados são insuficiência respiratória negligenciada, bloqueio simpático extenso, toxicidade por anestésicos locais, raquianestesia total, além da crescente consciência da predominância vagal como fator predisponente. No caso reportado, a paciente tinha 25 anos e estado físico ASA I e foi programada para lipoplastia estética. Após sedação com midazolam e fentanil, foi feita anestesia peridural nos interespaços T12-L1 e T2-T3 e inserção de cateter na punção inferior. A paciente foi mantida em decúbito dorsal horizontal durante 10 minutos. Em seguida, foi posicionada em decúbito ventral, evoluiu com parada cardíaca em assistolia 20 minutos após o bloqueio do neuroeixo. A equipe médica imediatamente colocou a paciente em decúbito dorsal e iniciou as manobras de ressuscitação cardiorrespiratória. O retorno da circulação espontânea foi obtido após 20 minutos de reanimação. É discutida neste relato a resposta vagal exacerbada como principal mecanismo causal do evento. O sucesso do desfecho da paciente em questão ressalta a importância da vigilância do anestesiologista, e do pronto reconhecimento e tratamento de mudanças de ritmo no eletrocardiograma.

Sudden motor and sensorial loss due to retroperitoneal hematoma during postoperative periods: a case report / Súbita perda sensitiva e motora devido a hematoma retroperitoneal durante os períodos de pós-operatório: relato de caso

Abstract A 68 year-old male patient was hospitalized for radical prostatectomy. He had no abnormal medical history including neurological deficit before the operation. Prior to general anesthesia, an epidural catheter was inserted in the L3-4 interspace for intraoperative and postoperative analgesia. After surgery for nine hours, he developed confusion and flaccid paralysis of bilateral lower extremities occurred. No pathology was detected from cranial computed tomography and diffusion magnetic resonance imaging no pathology was detected. His thoracic/lumbar magnetic resonance imaging. Intraabdominal pressure was shown to be 25 mmHg, and abdominal ultrasonography revealed progression in the inflammation/edema/hematoma in the perirenal region. The Bromage score was back to 1 in the right foot on the 24th hour and in the left foot on the 26th hour. Paraplegia developed in patients after epidural infusion might be caused by potentiated local anesthetic effect due to retroperitoneal hematoma and/or elevated intra-abdominal pressure.

Resumo Paciente do sexo masculino, 68 anos, hospitalizado para prostatectomia radical. O paciente não tinha história médica anormal, inclusive nem déficit neurológico, antes da operação. Antes da anestesia geral, um cateter peridural foi inserido no espaço intermédio L3-4 para analgesia no intra e pós-operatório. Após a cirurgia, que durou nove horas, o paciente desenvolveu confusão e paralisia flácida bilateral dos membros inferiores. Tomografia computadorizada de crânio e imagem de difusão por ressonância magnética não detectaram lesão. Os achados nas imagens de ressonância magnética torácica/lombar eram normais. A pressão intra-abdominal era de 25 mmHg e o ultrassom abdominal revelou progressão de inflamação/edema/hematoma na região perirrenal. O escore de Bromage voltou a 1 no pé direito na 24a hora e no pé esquerdo na 26a hora. A paraplegia desenvolvida nos pacientes após a infusão epidural pode ter sido causada por um efeito potencializado do anestésico local devido a hematoma retroperitoneal e/ou pressão intra-abdominal elevada.

Neuraxial anesthesia in patients with multiple sclerosis - a systematic review / Anestesia neuraxial em pacientes com esclerose múltipla - uma revisão sistemática

Abstract Background and objectives: Current guidelines for neuraxial analgesia in patients with multiple sclerosis are ambiguous and offer the clinician only a limited basis for decision making. This systematic review examines the number of cases in which multiple sclerosis has been exacerbated after central neuraxial analgesia in order to rationally evaluate the safety of these procedures. Methods: A systematic literature search with the keywords "anesthesia or analgesia" and "epidural, peridural, caudal, spinal, subarachnoid or intrathecal" in combination with "multiple sclerosis" was performed in the databases PubMed and Embase, looking for clinical data on the effect of central neuraxial analgesia on the course of multiple sclerosis. Results and conclusions: Over a period of 65 years, our search resulted in 37 reports with a total of 231 patients. In 10 patients multiple sclerosis was worsened and nine multiple sclerosis or neuromyelitis optica was first diagnosed in a timely context with central neuraxial analgesia. None of the cases showed a clear relation between cause and effect. Current clinical evidence does not support the theory that central neuraxial analgesia negatively affects the course of multiple sclerosis.

Resumo Justificativa e objetivos: As diretrizes atuais para analgesia neuraxial em pacientes com esclerose múltipla (EM) são ambíguas e oferecem ao clínico apenas uma base limitada para a tomada de decisão. Esta revisão sistemática examina o número de casos nos quais a EM foi exacerbada após analgesia neuraxial central para avaliar racionalmente a segurança desses procedimentos. Métodos: Uma busca sistemática da literatura com as palavras-chave "anestesia ou analgesia" e "epidural, peridural, caudal, espinhal, subaracnóideo ou intratecal" em combinação com multiple sclerosis foi feita nas bases de dados PubMed e Embase à procura de dados clínicos sobre a efeito da analgesia neuraxial central sobre o curso da esclerose múltipla. Resultados e conclusões: Durante um período de 65 anos, nossa busca resultou em 37 relatos com um total de 231 pacientes. Em 10 pacientes, a esclerose múltipla foi agravada e, em nove, a esclerose múltipla ou neuromielite óptica foi diagnosticada pela primeira vez em momento concomitante com a analgesia neuraxial central. Nenhum dos casos apresentou uma clara relação entre causa e efeito. A evidência clínica atual não sustenta a teoria de que a analgesia neuraxial central afeta negativamente o curso da esclerose múltipla.

Life-threatening acute subdural haematoma after combined spinal-epidural anaesthesia in labour / Hematoma subdural agudo potencialmente fatal após anestesia combinada raqui-peridural em parto

ABSTRACTBACKGROUND AND OBJECTIVES: Only few reports in literature have pointed out to the possibility of a cranial subdural haematoma formation associated with dural puncture during spinal or epidural analgesia. We herein describe such a rare case who was diagnosed to have acute subdural haematoma after combined spinal-epidural anaesthesia used in labour.CASE REPORT: A 34-year-old, primigravid women with a gestation of 38 weeks underwent caesarean section under combined spinal-epidural anaesthesia and gave birth to a healthy boy. Thirty-two hours after delivery, her moderate headache progressed to a severe headache associated with nausea and vomiting and later was more complicated with a generalized tonic-clonic seizure and ensuing lethargy. Computed tomography of the brain demonstrated a right-sided fronto-temporo-parietal acute subdural haematoma with diffuse cerebral oedema. She underwent urgent FTP craniotomy and evacuation of the haematoma. Early postoperative cranial computed tomography showed a clean operative site. Eight days after subdural haematoma surgery, she became lethargic again, and this time cranial computed tomography disclosed an extradural haematoma under the bone flap for which she had to undergo surgery again. Two days later, she was discharged home with Karnofsky performance score of 90/100. At follow-up exam, she was neurologically intact and her cranial computed tomography and magnetic resonance were normal.CONCLUSIONS: As conclusion, with the use of this combined spinal-epidural anaesthesia, it should be kept in mind that headache does not always mean low pressure headache associated with spinal anaesthesia and that a catastrophic complication of subdural haematoma may also occur.

RESUMOJUSTIFICATIVA E OBJETIVOS: Apenas alguns relatos na literatura mencionaram a possibilidade de formação de hematoma subdural craniano associada à punção durante a raquianestesia ou anestesia epidural. O presente relato descreve um caso tão raro que foi diagnosticado como hematoma subdural agudo após anestesia combinada raqui-peridural usada em parto.RELATO DE CASO: Paciente primípara, 34 anos, com 38 semanas de gestação, submetida à cesariana sob anestesia combinada raqui-peridural, deu à luz um menino saudável. Após 32 horas do parto, a dor de cabeça moderada da paciente progrediu para dor de cabeça intensa associada a náusea e vômito e se complicou subsequentemente com crise convulsiva generalizada tônico-clônica e consequente letargia. Tomografia computadorizada do cérebro revelou hematoma subdural agudo do lado direito em região frontotemporoparietal (FTP) com edema cerebral difuso. A paciente foi submetida à craniotomia FTP de urgência e evacuação do hematoma. Tomografia computadorizada do crânio no pós-operatório precoce mostrou um sítio operatório limpo. Oito dias após a cirurgia do hematoma subdural, a paciente voltou a ficar letárgica e, dessa vez, a tomografia computadorizada revelou um hematoma extradural sob o retalho ósseo que exigiu outra cirurgia. Dois dias depois, a paciente recebeu alta hospitalar com classificação de desempenho Karnofsky de 90/100. Ao exame de acompanhamento, a paciente apresentou-se neurologicamente intacta e sua tomografia computadorizada e ressonância magnética estavam normais.CONCLUSÃO: Ao usar a anestesia combinada raqui-peridural deve-se ter em mente que dor de cabeça nem sempre significa dor de cabeça hipotensiva associada à raquianestesia e que uma complicação catastrófica de hematoma subdural também pode ocorrer.

Epidural levobupivacaine alone or combined with different morphine doses in bitches under continuous propofol infusion / Levobupivacaína isolada ou associada à morfina em diferentes doses pela via peridural em cadelas sob infusão contínua de propofol

The aim of this study was to assess the cardiopulmonary, analgesic, adverse effects, serum concentration of cortisol and plasma levels of levobupivacaine and morphine in bitches undergoing propofol anesthesia and epidural analgesia with levobupivacaine alone or combined with morphine. This was a randomized 'blinded' prospective clinical study using 32 adult bitches weighing 9.8±4.1kg that were admitted for elective ovariohysterectomy. Twenty minutes after administration of acepromazine and midazolam, anesthesia was induced with propofol (4mg kg-1) and maintained by a continuous rate infusion (CRI). Each animal was randomly assigned to one of four epidural groups: GL = levobupivacaine alone (0.33mg kg-1); GLM0.1 = levobupivacaine and morphine (0.1mg kg-1); GLM0.15 = levobupivacaine and morphine (0.15mg kg-1); and GLM0.2 = levobupivacaine and morphine (0.2mg kg-1)...

Objetivou-se avaliar os efeitos cardiovasculares, analgésico, adversos, a concentração sérica de cortisol e os níveis plasmáticos de levobupivacaína e morfina em cadelas submetidas à infusão contínua de propofol e analgesia peridural com levobupivacaína isolada ou associada à morfina. Para tanto, realizou-se um estudo clínico prospectivo randomizado com 32 cadelas adultas pesando 9,8 ± 4,1kg, que foram submetidas à ovário-histerectomia eletiva. Vinte minutos após a administração de acepromazina e midazolam, os animais foram induzidos com propofol (4mg/kg) e mantidos por uma infusão contínua (CRI) do mesmo fármaco. Cada animal foi alocado aleatoriamente em um dos quatro grupos: GL = levobupivacaína isolada (0,33mg/kg); GLM0,1 = levobupivacaína + morfina (0,1mg/kg); GLM0,15 = levobupivacaína + morfina (0,15mg/kg) e GLM0,2 = levobupivacaína + morfina (0,2mg/kg)...

Anestesia peridural: vantagens e desvantagens na prática anestésica atual / Epidural anesthesia: advantages and disadvantages in the current anesthesia practice

Estudos recentes foram realizados com o intuito de evidenciar vantagens no uso da anestesia peridural em diversas especialidades. Na cirurgia cardíaca, ela reduziu o risco de arritmias supraventriculares e complicações pulmonares sem influenciar diretamente na mortalidade, na incidência de infarto agudo do miocárdio e de acidente cerebrovascular. Em procedimentos ortopédicos promoveu bom controle da dor pós-operatória, principalmente em cirurgias de correção de escoliose. Todavia, não teve impacto significativo em desfechos pós-operatórios. Nas cirurgias urológicas oncológicas não foi encontrada associação entre o uso do bloqueio peridural e a diminuição da recorrência tumoral. Houve redução do sangramento perioperatório e controle adequado da dor sem ocorrer, no entanto, alteração no tempo de internação hospitalar. Nas cirurgias torácicas, atualmente tem perdido espaço para o bloqueio paravertebral, que se mostrou igualmente eficaz e com melhor perfil de efeitos colaterais. Na população pediátrica, o bloqueio peridural se destaca frente às outras modalidades analgésicas, sobretudo em cirurgias de grande porte. O risco de complicações associadas diminui progressivamente com o aumento da idade e a execução da técnica sob anestesia geral ou sedação profunda é aparentemente segura. Em gestantes, a analgesia peridural permite alívio da dor e não há evidência de que aumenta a incidência de cesáreas, porém em situações de urgência o bloqueio subaracnóideo é preferido. Estudos que avaliaram a anestesia peridural em cirurgias abdominais verificaram retorno precoce do trânsito gastrintestinal, sem aumento na incidência de deiscência anastomótica. O uso do bloqueio em cirurgias laparoscópicas ainda é controverso.

Recent studies have been conducted to elucidate the advantages of using epidural anesthesia in several specialties. In cardiac surgery, it was shown to reduce supraventricular arrhythmias and pulmonary complications risk, without having a direct effect on mortality,myocardial infarction and cerebrovascular events. Epidural anesthesia produced better pain control after orthopedic procedures, especially after scoliosis correction, however it has no significant impact in postoperative outcomes. No correlation between the use of epidural block and tumor recurrence could be found in urological oncological surgeries. Reduced bleeding and good pain control has been achieved without reduction on hospitalization duration. In thoracic surgeries, recently, it is being replaced by paravertebral block, which can be equally effective and with better collateral profile. Epidural anesthesia is preferable over the other analgesic modalities, in the pediatric population, especially for major procedures. The complications risk with its use reduces progressively with increasing age and the execution of the technique under general anesthesia or deep sedation is apparently safe. Epidural analgesia in parturients relief pain and there is no evidence on increasing cesarean rate, but in the emergency scenarios subarachnoid spinal anesthesia is still preferred. Studies have evaluated the epidural blockade in abdominal surgeries, it was shown to allow fast return of bowel movements without increasing the incidence of anastomotic leakage. Its use in laparoscopic surgery is still controversial.

Comportamiento de la cefalea post punción dural / The cefalea behaviour in dural post punction

Introducción: los síntomas subjetivos de la cefalea post punción lumbar se relacionan con los elementos neurales estimulados. Objetivo: caracterizar el comportamiento de la cefalea post punción dural en pacientes tratados con bloqueo espinal en los hospitales Lucía Íñiguez y Vladimir I Lenin. Métodos: estudio descriptivo y transversal en 80 pacientes de 16 a 60 años, tratados en cirugía con anestesia espinal en el servicio de anestesiología de los hospitales Lucia Iñiguez y Vladimir I Lenin entre noviembre de 2012 y abril de 2013, según estado físico: pacientes sanos y pacientes con enfermedades sistémicas compensadas. Se aplicó el método de chi cuadrado. Resultados: entre las edades de 16 ­ 30 años, predomina el grupo ASA I en la aparición de cefalea post punción dural con el 15 por ciento, la cefalea post punción dural apareció en el 10,0 por ciento de los pacientes donde se utilizó aguja número 22G, el 16,3 por ciento presentó cefalea post punción dural al movilizarse fuera de cama, en el 8,8 por ciento apareció la cefalea post punición dural en las primeras 24h de los pacientes estudiados y en el 7,5 por ciento, después de las 24h. Conclusiones: predominó el grupo de 16 a 30 años y género femenino. Según el estado físico, se presentó la cefalea con mayor frecuencia en pacientes sanos. La movilización temprana del paciente contribuye a disminuir la frecuencia de aparición de la cefalea(AU)

Introduction: The subjective symptoms of the headache post lumbar puncion are related with the elements stimulated neurals area. Objective: To determine the headache appearance post puncion dural in subjected patients to spinal blockade. Methods: A descriptive of prospective traverse court in 80 patients in the ages understood among 16 y 60 subjected to surgery with spinal anesthesia in the service of anesthesiology of the hospital Lucia Iñiguez Landin and Vladimir I Lenin between nobember 2012 and april 2013, king into account phisical state ASAI and ASAII. Results: Between 16-30 years old, predominantly ASA I group in the occurrence of post dural puncture headache with 15 percent post-dural puncture headache appeared in 10.0 percent of patients where number 22G needle was used, the 16.3 percent had post-dural puncture headache to move out of bed and post dural punishment appearing in the first 24 hours in 8.8 percent of the patients and headache in 7.5 percent appeared after 24h. Conclusions: The prevailed age group between 16 and 30 years and female gender. It is better to use spinal needle of the fine caliber in young patients and to consider that the early mobilization of the patient contributes to diminish the frequency of the appearance of the cefalea(AU)

Comparação entre bloqueios peridural e paravertebral torácicos contínuos para analgesia pós-operatória em pacientes submetidos a toracotomias: revisão sistemática / Comparison between continuous thoracic epidural and paravertebral blocks for postoperative analgesia in patients undergoing thoracotomy: systematic review / Comparación entre bloqueos epidural y paravertebral torácicos continuos para analgesia postoperatoria en pacientes sometidos a toracotomías: revisión sistemática

INTRODUÇÃO E OBJETIVOS: Toracotomia é um procedimento associado à dor pós-operatória de forte intensidade. O bloqueio peridural (BPD) é considerado o padrão-ouro para o seu controle. O bloqueio paravertebral (BPV) é uma opção para o controle da dor pós-operatória. O objetivo deste estudo foi fazer metanálises focadas nas comparações entre as analgesias com bloqueio peridural torácico ou paravertebral contínuos quanto à eficácia relativa no controle da dor pós-toracotomia e à incidência de efeitos adversos. MÉTODOS: O estudo seguiu o protocolo Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Foram analisados desfechos, primário (dor pós-operatória em repouso), e secundários (retenção urinária, náuseas e vômitos e hipotensão arterial). A diferença média ponderada foi estimada para as variáveis contínuas e as razões de chances para as variáveis categóricas. RESULTADOS: Foram incluídos oito estudos prospectivos controlados de alocação aleatória. As metanálises não demonstraram diferenças estatisticamente significantes entre as duas técnicas quanto ao desfecho da dor pós-operatória em repouso nos momentos 4h, 8h, 12h, 16h, 20h, 24h, 36h e 48h. A incidência de retenção urinária foi maior no grupo submetido ao BPD (RC = 7,19; IC95 = 1,87-27,7). A ocorrência de hipotensão foi maior no grupo submetido ao BPD (RC = 10,28; IC95 = 2,95-35,77). Não houve diferença estatisticamente significante entre os dois grupos em relação ao desfecho náuseas/vômitos (RC=3,00; IC95=0,49-18,45). CONCLUSÃO: Não se observaram diferenças estatisticamente significantes quanto ao alívio da dor pós-toracotomia quando comparados os tratamentos BPD e BPV. O tratamento BPV mostrou menor incidência de efeitos colaterais com redução na frequência de retenção urinária e hipotensão.

BACKGROUND AND OBJECTIVE: Thoracotomy is a procedure associated with postoperative severe pain. Epidural block (EB) is considered the gold standard for its control. Paravertebral block (PVB) is an option for the management of postoperative pain. The aim of this study was to evaluate by meta-analyses the effectiveness of continuous thoracic epidural and paravertebral blocks for pain management after thoracotomy and the incidence of adverse effects. METHOD: The study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. We analyzed primary (postoperative pain at rest) and secondary outcomes (urinary retention, nausea, vomiting, hypotension). We estimated the weighted mean difference for continuous variables and odds ratios for categorical variables. RESULTS: We included eight prospective, randomized, controlled studies. Meta-analysis showed no statistically significant differences between the two techniques regarding the outcomes of postoperative pain at rest at four, eight, 12, 16, 20, 24, 36, and 48 hours. Incidence of urinary retention was higher in EP group (OR = 7.19, CI95 = 1.87 to 27.7). The occurrence of hypotension was higher in PVB group (OR = 10.28, 95 = 2.95 to 35.77). There was no statistically significant difference between both groups regarding the outcome nausea/vomiting (OR = 3.00, CI95 = 0.49 to 18.45). CONCLUSION: There were no statistically significant differences in pain relief after thoracotomy between EB and PVB. PVB showed a lower incidence of side effects with reduced frequency of urinary retention and hypotension.

INTRODUCCIÓN Y OBJETIVOS: La toracotomía es un procedimiento asociado con el dolor postoperatorio de fuerte intensidad. El bloqueo epidural (BEP) se le considera como el estándar oro para su control. El bloqueo paravertebral (BPV) es una opción para el control del dolor postoperatorio. El objetivo de este estudio fue hacer un meta-análisis centrándose en las comparaciones entre analgesia pos-toracotomía con bloqueo epidural torácico o paravertebral continuos, en cuanto a la eficacia relativa en el control del dolor pos-toracotomía y a la incidencia de los efectos adversos. MÉTODOS: El estudio secundó el protocolo Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Se analizaron los resultados primarios (dolor Postoperatorio en reposo) y secundarios (retención urinaria, náuseas y vómitos e hipotensión arterial). La diferencia promedio ponderada se estimó para las variables continuas y las razones de chances para las variables categóricas. RESULTADOS: Fueron incluidos ocho estudios prospectivos controlados de ubicación aleatoria. Los meta-análisis no arrojaron diferencias estadísticamente significativas entre las dos técnicas en cuanto al resultado del dolor postoperatorio en reposo en los momentos 4h, 8h, 12h, 16h, 20h, 24h, 36h y 48h. La incidencia de retención urinaria fue mayor en el grupo sometido al BEP (RC = 7,19; IC95 = 1,87-27,7). El surgimiento de hipotensión aumentó en el grupo sometido al BEP (RC = 10,28; IC95 = 2,95-35,77). No hubo diferencia estadísticamente significativa entre los dos grupos con relación al resultado náuseas/vómitos (RC=3,00; IC95=0,49-18,45). CONCLUSIONES: No se observaron diferencias estadísticamente significativas en cuanto al alivio del dolor pos-toracotomía cuando se compararon los tratamientos BEP y BPV. El tratamiento BPV mostró una menor incidencia de efectos colaterales con una reducción en la frecuencia de retención urinaria e hipotensión.

Epidural catheterization in cardiac surgery: The 2012 risk assessment.

Aims and Objectives: The risk assessment of epidural hematoma due to catheter placement in patients undergoing cardiac surgery is essential since its benefits have to be weighed against risks, such as the risk of paraplegia. We determined the risk of the catheter-related epidural hematoma in cardiac surgery based on the cases reported in the literature up to September 2012. Materials and Methods: We included all reported cases of epidural catheter placement for cardiac surgery in web and in literature from 1966 to September 2012. Risks of other medical and non-medical activities were retrieved from recent reviews or national statistical reports. Results: Based on our analysis the risk of catheter-related epidural hematoma is 1 in 5493 with a 95% confidence interval (CI) of 1/970-1/31114. The risk of catheter-related epidural hematoma in cardiac surgery is similar to the risk in the general surgery population at 1 in 6,628 (95% CI 1/1,170-1/37,552). Conclusions: The present risk calculation does not justify not offering epidural analgesia as part of a multimodal analgesia protocol in cardiac surgery.

Cerebral sinus thrombosis secondary to epidural anaesthesia

Cerebral venous sinus thrombosis [CVST] is an uncommon, and yet potentially fatal, condition; we present a rare case of CVST as a complication of epidural anaesthesia used for caesarean section, we review different aspects of CVST in terms of epidemiology, aetiology, investigations, and treatment, as well as most acceptable theory explaining the pathogenesis in our case report

Postpartum complicated by transverse myelitis / Postparto complicado por mielitis transversa

Transverse myelitis is a very rare neurological condition associated with immunologic and infectious conditions causing interruption of the neuroanatomical pathways in a transverse plane in the spinal cord. Herein is described the fatal case of a patient that developed transverse myelitis after a Caesarean delivery, probably related to the epidural analgesia.

La mielitis transversa es un trastorno neurológico poco común, asociado con problemas inmunológicos e infecciosos que causan interrupciones de las vías neuroanatómicas en el plano transversal de la médula espinal. Aquí se describe el caso fatal de una paciente que desarrolló mielitis transversal luego de un parto con cesárea, probablemente en relación con la anestesia epidural.

Quadriplegia e afonia após punção epidural: relato de caso / Quadriplegia and aphonia after epidural puncture: a case report

Justificativa e objetivos: complicações de anestesia epidural são pouco frequentes, principalmente aquelas que levam à perda de funções sensoriais com envolvimento de áreas cognitivas. Diversas hipóteses podem ser aventadas, entretanto, não se pode afirmar com exatidão o diagnóstico que levou ao transcurso clínico. Medidas simples e eficazes odem contornar a intercorrência com segurança. Relato do caso: paciente de 36 anos ASA I, submeteu-se à anestesia epidural para procedimento em membro inferior D, desenvolveu após 15 min quadriplegia e afonia, com agitação moderada. (AU)

Justification and objectives: Complications upon epidural anesthesia are rare, specially those leading to loss of sensory functions and compromise of cognitive areas. Several hypotheses can be formulated, but no diagnosis is precise enough to explain the cause of such incidences. Simple and efficient measures may help overcome the intercurrence safely. Case report: A 36-year-old ASA I patient that had epidural anesthesia applied for a procedure in the right lower limb developed quadriplegia and aphonia with mild agitation upon 15 minutes.(AU)

PDPH by using gauge of needles

There is increase incidence of Lower Segment Caesarean section [LSCS] being performed under sub-arachnoid block [SAB] because it is relatively safe. One of the complications of SAB is Post Dural Puncture Headache [PDPH] which is very distressing to the patient. To observe the incidence of PDPH by using two different types of spinal needle of 25 gauge in females undergoing LSCS under SAB. Currently, in our setup 25G cutting [quincke] spinal needle is routinely used. Randomized controlled trial. Department of Anesthesia, Officers Family Hospital, Rawalpindi Cantt. 6 months from 15 February 2011 to 15 July 2011. 100 pregnant patients undergoing elective CD under spinal anaesthesia were randomized into two group A and B. Group A received SAB with 25G Quincke needle; Group B-received SAB with 25G pencil-point needle. Follow up was done up to 72 hours after the surgery. Data obtained through study was analysed through computer software SPSS version 12. quantitative variables like age, weight and height are presented as mean and standard deviation. The frequency of PDPH was qualitatively analysed in percentage. The frequency of PDPH was compared between two groups with the application of Chi-square as test of significance at P-value <0.05. It was found that the incidence of PDPH with Quincke [cutting tip] needle was significantly higher [7.%] as compared to pencil point needle [0%]. Pencil-point needle is associated with lesser incidence of PDPH and should be preferred to Quincke needle to achieve SAB in patients undergoing LSCS