Brazilian Journal of Anesthesiology
https://app.periodikos.com.br/journal/rba/article/doi/10.1590/S0034-70942001000400008
Brazilian Journal of Anesthesiology
Clinical Information

Pneumoencéfalo após anestesia peridural: relato de caso

Pneumocephalus after epidural anesthesia: case report

Angélica de Fátima de Assunção Braga; Franklin Sarmento da Silva Braga; Glória Maria Braga Potério; Eugesse Cremonesi; Luiz Humberto David; Rogério Schimidtt

http://dx.doi.org/10.1590/S0034-70942001000400008 Braz J Anesthesiol, vol.51, n4, p.325-330, 2001
PDF Português
PDF English
Downloads: 2
Views: 1723

Resumo

JUSTIFICATIVA E OBJETIVOS: O bloqueio peridural constitui técnica utilizada para alívio da dor durante o trabalho de parto. Apesar das vantagens, não é isenta de complicações, como, por exemplo, o pneumoencéfalo. O objetivo deste relato é apresentar um caso de pneumoencéfalo iatrogênico, diagnosticado após bloqueio peridural, com punção acidental de duramáter. RELATO DO CASO: Paciente de 16 anos, estado físico ASA I, sem antecedentes anestésicos, submetida a bloqueio peridural contínuo para analgesia de parto. Após várias tentativas de punções no espaço L3-L4, ocorreu punção acidental de duramáter. Optou-se por nova punção peridural em L2-L3, sem sucesso. Foi tentada outra punção em L3-L4, e após identificação do espaço peridural empregando-se a técnica da perda da resistência com ar, injetou-se o anestésico local e fentanil, seguido de passagem do cateter. Após 20 minutos da instalação do bloqueio, ocorreu sofrimento fetal, com indicação de cesariana, sendo administrada dose complementar de anestésico local pelo cateter. A paciente permaneceu hemodinamicamente estável e consciente durante a cirurgia, com lenta recuperação do bloqueio motor (14 h). No pós-operatório, apresentou dois episódios de crise convulsiva, com intervalo de 12 horas entre eles, que reverteram espontaneamente. A avaliação neurológica era normal e a tomografia computadorizada revelou imagem com densidade de ar compatível com pneumoencéfalo. A paciente teve alta três dias após, sem seqüelas. CONCLUSÕES: O caso confirma a possibilidade de se causar pneumoencéfalo iatrogênico durante a realização de bloqueio peridural, empregando-se a técnica da perda de resistência ao ar para a identificação do espaço peridural. Na presença de sinais e sintomas de irritação meníngea, a tomografia computadorizada é o meio diagnóstico recomendado para o diagnóstico diferencial entre pneumoencéfalo e as demais causas.

Palavras-chave

CIRURGIA, COMPLICAÇÕES, Neurológica, TÉCNICAS ANESTÉSICAS, Regional

Abstract

BACKGROUND AND OBJECTIVES: Epidural block is the technique of choice to relieve labor pain. In spite of the advantages, it is not free from complications, such as pneumocephalus. This report aimed at presenting a case of iatrogenic pneumocephalus, diagnosed after epidural block with accidental dural puncture. CASE REPORT: A 16-year old patient, physical status ASA I, without anesthetic history was submitted to continuous epidural block for labor analgesia. After several puncture attempts at L3-L4 interspace, there was an accidental dural puncture. A new epidural puncture at L2-L3 was attempted without success. Another puncture in L3-L4 was attempted and after epidural space identification through the technique of loss of resistance to air, local anesthetics and fentanyl were injected followed by catheter introduction. Twenty minutes after blockade fetal distress was observed and cesarean section was indicated with an additional dose of local anesthetic administered through the catheter. Patient remained hemodynamically stable and conscious during surgery with a slow motor block recovery (14 h). There were two postoperative seizures with an interval of 12 h between them, which reverted spontaneously. Neurological evaluation was normal and CT scan revealed an image with air density compatible with pneumocephalus. Patient was discharged 3 days later without sequelae. CONCLUSIONS: This case confirms the possibility of iatrogenic pneumocephalus during epidural block using the loss of resistance to air technique to identify the epidural space. In the presence of signs and symptoms of meningeal irritation, CT is the diagnostic tool recommended for the differential diagnosis of pneumocephalus and other causes.

Keywords

ANESTHETIC TECHNIQUES, Regional, COMPLICATIONS, Neurologic, SURGERY

References

Ash KM, Cannon JE, Biehl DR. Pneumocephalus following attempted epidural anaesthesia. Can J Anaesth. 1991;38:772-774.

Durán L, Hurtado J, Sante L. Bloqueo subdural accidental en anestesia epidural. Rev Esp Anestesiol Reanim. 1993;40:41-42.

Gyutsche BB. Complications of regional anesthesia in obstetrics. . 1987:173.

Cousins MJ, Bridenbaugh PO. Neural Blockade in Clinical Anesthesia and Management of Pain. 1988.

Sicard JA, Forestier J. Radiographic method for exploration of the extradural space using lipidol. Rev Neurol. 1921;28:1264.

Harrell LE, Drake ME, Massey EW. Pneumocephaly from epidural anesthesia. South Med J. 1983;76:399-400.

Saberski LR, Kondamuri S, Osinubi OY. Identification of the epidural space: is loss of resistance to air a safe technique? A review of the complications related to the use of air. Reg Anesth. 1997;22:3-15.

Reasoner DK, Todd MM, Scamman FL. The incidence of pneumocephalus after supratentorial craniotomy. Anesthesiology. 1994;80:1008-1012.

Heinz ER. Techniques in Imaging of the Spine: Myelography. The Clinical Neurosciences: Neuroradiology. 1984:795-817.

Finch M, Morgan G. Traumatic pneumocephalus following head injury. Anaesthesia. 1991;46:385-387.

Candan S, Katelioglu M, Ceylan S. Otogenic brain abscess with pneumocephalus. Infection. 1990;18:191-192.

Dogliotti AM. Segmental peridural anesthesia. Am J Surg. 1933;20:107-118.

Heldt TJ, Moloney JC. Negative pressure in epidural space. Am J Med Sci. 1928;175:371-376.

Davidson JT. Identification of the epidural space. Anesthesiology. 1966;27:859.

Sharrock NE. Recordings of, and an anatomical explanation for, false positive loss of resistance during lumbar extradural analgesia. Br J Anaesth. 1979;51:253-258.

Macintosh R. Lumbar puncture and spinal analgesia. 1985:211-215.

Valentine SJ, Jarvis AP, Shutt LE. Comparative study of the effects of air or saline to identify the extradural space. Br J Anaesth. 1991;66:224-227.

Baylot D, El Khouri Z, Aarab A. La pneumatocèle cérébrale après anesthésie péridurale: une complication rare?. Ann Fr Anesth Reanim. 1993;12:431-433.

Krisanda TJ, Laucks SO. Pneumocephalus following an epidural blood patch procedure: an unusual cause of severe headache. Ann Emerg Med. 1994;23:129-131.

Avellanal M, Olmedilla L, Ojea R. Pneumocephalus after spinal anesthesia. Anesthesiology. 1996;85:423-425.

Rodrigo P, Garcia JM, Ailagas J. Crisis convulsiva generalizada relacionada con neumoencéfalo tras punción dural inadvertida en una paciente obstétrica. Rev Esp Anestesiol Reanim. 1997;44:247-249.

Mateo E, Lopez-Alarcon MD, Moliner S. Epidural and subarachnoidal pneumocephalus after epidural technique. Eur J Anaesthesiol. 1999;16:413-417.

Sherer DM, Onyeije CI, Yun E. Pneumocephalus following inadvertent intrathecal puncture during epidural anesthesia: a case report and review of the literature. J Matern Fetal Med. 1999;8:138-140.

Fedder SL. Air ventriculogram serendipitously discovered after epidural anesthesia. Surg Neurol. 1988;30:242-244.

Ahlering JR, Brodsky JB. Headache immediately following attempted epidural analgesia in obstetrics. Anesthesiology. 1980;52:100-101.

Taveras JM, Wood EH. Intracranial Pneumography: Morbidity and Complications. Diagnostic Neuroradiology. 1964:1248-1266.

Katz Y, Markovits R, Rosenberg B. Pneumoencephalus after inadvertent intrathecal air injection during epidural block. Anesthesiology. 1990;73:1277-1279.

Petty R, Stevens R, Erickson S. Inhalation of nitrous oxide expands epidural air bubbles. Reg Anesth. 1996;21:144-148.

Aida S, Taga K, Yamakura . Headache after attempted epidural block: the role of intrathecal air. Anesthesiology. 1998;88:76-81.

Laviola S, Kirvelä M, Spoto MR. Pneumocephalus with intense headache and unilateral pupillary dilatation after accidental dural puncture during epidural anesthesia for cesarean section. Anesth Analg. 1999;88:582-583.

Brindle-Smith G, Barton F, Watt J. Extensive spread of local anesthetic solution following subdural insertion of an epidural catheter during labour. Anaesthesia. 1984;39:355-358.

5dd814c10e8825a35f13f287 rba Articles
Links & Downloads
2352-2291 (Electronic) 0104-0014 (Printed)
Braz J Anesthesiol ©2024 All rights reserved.

Braz J Anesthesiol

Share this page
Page Sections