[Unusual complication following placement of an epidural catheter]. / Ungewöhnliche Komplikation nach Anlage eines Periduralkatheters.

We report an unusual complication following placement of a thoracic epidural catheter in a patient that had undergone surgery for pulmonary metastases of a malignant melanoma. The intra- and postoperative course was initially without complications. At 2 days, there was a small, conspicuous swelling above the site of epidural puncture, which was neither reddened nor painful. No neurological deficits were observed, and the patient explained that he had been aware of the swelling for more than 6 months; thus, the epidural catheter was not deemed to be responsible. After catheter removal on day 4, an apparently purulent fluid drained from the puncture site. Although the patient had not reported this in the initial medical examination, he now explained that this cutaneous process had been squeezed out by his wife several times before. We initially obtained an exudate by means of ultrasound-guided puncture, and two epidermal cysts were detected on subsequent magnetic resonance imaging (MRI). The epidural catheter had been placed through one of these epidermal cysts. After reassessing the medical files, we found the earlier reports of two positron emission tomographies in which two epidermoid cysts were described at the level of thoracic vertebra 5/6 and 6/7. Facklamia hominis was detected in the pure culture. To avoid bacterial infection, we treated the patient for 7 days with antibiotics. The clinical course was without further pathological findings.

Tramadol frente a morfina en la analgesia peridural posoperatoria de pacientes con histerectomía abdominal / Tramadol versus morphine for postoperative peridural analgesia in patients with abdominal hysterectomy

Introducción: el tratamiento del dolor posoperatorio es necesario para evitar sus efectos desfavorables. Objetivo: comparar la analgesia posoperatoria con el uso de tramadol y morfina por vía peridural en pacientes con histerectomía abdominal. Métodos: se realizó un estudio observacional analítico, longitudinal prospectivo en 140 pacientes que se les efectuó histerectomía por vía abdominal en el Hospital Militar Central "Dr. Carlos J. Finlay". Se aplicó anestesia general orotraqueal y se utilizó el catéter epidural para el manejo del dolor posoperatorio. Se dividieron aleatoriamente en dos grupos, cada uno con 70 pacientes. Un grupo recibió analgesia con morfina, 4 mg, y el otro tramadol, 100 mg. Se estudiaron las variables: duración, calidad de la analgesia posoperatoria y presencia de reacciones adversas. Resultados: la duración de la analgesia posoperatoria fue mayor en el grupo en que se empleó morfina (16,7 ± 4,0 h) que en el de tramadol (13,6 ± 4,2 h). Los valores de la escala visual análoga resultaron más elevados en el grupo Tramadol y con menor cantidad de reacciones adversas (38,6 por ciento) comparado con el grupo Morfina (55,7 por ciento). Conclusiones: la duración y la calidad de la analgesia posoperatoria en las pacientes que se les efectuó histerectomía, resultó mayor con el empleo de morfina peridural, aunque la utilización del tramadol por igual vía, constituye una alternativa eficaz y con menor incidencia de efectos adversos

Introduction: the treatment of postoperative pain is necessary to prevent its unfavorable effects. Objective: compare the use of peridural tramadol versus morphine for postoperative analgesia in patients with abdominal hysterectomy. Methods: an observational analytical prospective longitudinal study was conducted with 140 patients who underwent abdominal hysterectomy at Dr. Carlos J. Finlay Central Military Hospital. General orotracheal anesthesia was administered and an epidural catheter used to manage postoperative pain. Patients were randomly distributed into two groups, each with 70 members. One group received analgesia with morphine 4 mg and the other tramadol 100 mg. The variables studied were duration, quality of postoperative analgesia and presence of adverse reactions. Results: duration of postoperative analgesia was longer in the morphine group (16.7 ± 4.0 h) versus the tramadol group (13.6 ± 4.2 h). Visual analog scale values were higher in the Tramadol group with fewer adverse reactions (38.6 percent) versus the Morphine group (55.7 percent). Conclusions: the duration and quality of postoperative analgesia in patients with hysterectomy were greater with the use of peridural morphine, though the use of peridural tramadol is an effective alternative with fewer adverse effects.

Fístula cutánea de líquido cefalorraquídeo por catéter peridural / Cutaneous fistula of cerebrospinal fluid by peridural catheter

Introducción: La fístula de líquido cefalorraquídeo tras la colocación de un catéter peridural para el tratamiento del dolor crónico en una paciente oncológica es una complicación rara. Objetivos: Describir la conducta perioperatoria y la evolución de una paciente oncológica con dolor crónico, en la que se utilizó para analgesia un catéter peridural durante tiempo prolongado, que presentó una fístula de líquido cefalorraquídeo. Presentación de caso: Paciente femenina de 32 años de edad con un carcinoma de ovario avanzado a la que se le colocó un catéter peridural a nivel de L2- L3 para la administración de analgesia con anestésicos locales y morfina liofilizada. A los 28 días comenzó con pérdida abundante de líquido en el sitio de inserción del catéter. Se estudió por citología y se corroboró la presencia de líquido cefalorraquídeo, por lo que se retiró el catéter. Se indicó, abundante reposición de líquidos y aminofilina por vía oral una tableta cada 8 horas. Se realizó vendaje compresivo del orificio cutáneo. A las 24 horas se mantiene la pérdida de líquido por lo que se realizó parche hemático. Evolucionó satisfactoriamente. Conclusiones: Las fístulas cutáneas cerebroespinales constituyen complicaciones muy poco frecuentes en la práctica anestesiológica, de etiología multifactorial e imprecisa, con una fundamentación fisiopatológica y una conducta terapéutica aun por definir, en las que el parche epidural con sangre autóloga parece ser una alternativa adecuada.

The cerebrospinal fluid fistula after the insertion of a peridural catheter to treat the chronic pain in an Oncology patient is an uncommon complication. Objectives: To describe the perioperative behavior and the course of an Oncology patient presenting with chronic pain using a long-term peridural catheter for analgesia, as well as a cerebrospinal fluid fistula. Case presentation: A female patient aged 32 presenting with an advanced ovarian carcinoma; a peridural catheter was passed at L2-L3 level to administration of analgesia with local anesthetics and lyophilized morphine. At 28 days she had an abundant loss of fluid in the insertion site of catheter. She was studied by cytology corroborating the presence of cerebrospinal fluid and removing the catheter. The prescription was a significant reestablishment of fluid and aminophyline per os (a tablet every 8 hours). A compressing bandage was placed over the cutaneous orifice. At 24 hrs the fluid loss subsists being necessary a hematic patch. She had a satisfactory course. Conclusions: The cutaneous cerebrospinal fistulae are uncommon complications in the anesthesia practice; it is of multifactorial and imprecise origin with a pathophysiological basis and a therapeutical behavior still not well defined where the epidural patch with autologous blood seems a appropriate alternative.