Anästhesiol Intensivmed Notfallmed Schmerzther 2007; 42(1): 42-52
DOI: 10.1055/s-2007-969043
Fachwissen: Topthema: Postoperative Akutschmerztherapie

© Georg Thieme Verlag Stuttgart · New York

Postoperative Akutschmerztherapie - Schwere Komplikationen durch Regionalanalgesieverfahren - Symptome, Diagnose und Therapie

Complications of Regional Anesthesia: Diagnostic and Management>Esther M. Pogatzki-Zahn, Manuel Wenk, Hansdetlef Wassmann, Walter L. Heindel, Hugo Van Aken
Further Information

Publication History

Publication Date:
26 January 2007 (online)

Zusammenfassung

Regionalanästhesieverfahren haben mittlerweile einen bedeutenden Stellenwert in der perioperativen Schmerztherapie. Neben den unbestrittenen Vorteilen (v.a. der thorakalen Epiduralanalgesie) hinsichtlich effektiver Analgesie und erniedrigter Patientenmorbidität v.a. bei Risikopatienten besteht aber ein gewisses Risiko für das Auftreten von Komplikationen wie einem epiduralen Hämatom, einem epiduralen Abszess oder einer systemischen Lokalanästhetika-Intoxikation. Epidurale Raumforderungen nach Anlage eines Katheters sind zwar seltene Komplikationen, können aber bis hin zu irreversiblen neurologischen Schäden wie einer kompletten Querschnittsymptomatik führen. Daher ist eine schnelle und zielgerichtete Diagnostik (MRI ist Goldstandard) und Therapie (ggf. chirurgische Entlastung) für die klinischen Prognose des Patienten entscheidend. Eine weitere, seltene, aber potenziell letale Komplikation regionaler Analgesieverfahren ist eine systemische Lokalanästhetika-Intoxikation mit den daraus resultierenden Folgen, insbesondere zentralnervöser sowie myokardialer und vaskulärer Blockade von Natriumkanäle mit hämodynamisch relevanten und zum Teil therapierefraktären kardialen Rhythmusstörungen. In der vorliegenden Übersichtsarbeit wird anhand der aktuellen Literatur die Inzidenz wichtiger, durch neuroaxiale Analgesieverfahren verursachte Komplikationen beurteilt, klinische Symptome beschrieben sowie die entsprechenden diagnostischen und therapeutischen Möglichkeiten diskutiert.

Summary

Neuroaxial anesthesia has become an integral part of perioperative pain therapy and provides several advantages over systemic opioids. Despite these benefits, rare but serious complications occur with epidural analgesia including epidural haematoma, spinal-epidural infections and local anesthetic cardiac toxicity.

Epidural haematoma and epidural abscess after catheter placement may cause irreversible neurological complications and an immediate diagnostic and therapeutic approach is crucial to assure complete recovery. Furthermore, local anesthetic-induced cardiac toxicity is another rare but potentially lethal complication during regional anesthesia. Based on lipophilic and hydrophilic properties, local anesthetics can interfere with ion channels such as sodium, potassium and calcium channels of the CNS and the heart leading to severe neuronal and cardiac (arrhythmia and contractile depression) adverse effects. In this review we take an in-depth look at severe complications associated with regional anesthesia, describe their symptoms and discuss appropriate diagnostic and therapeutical approaches.

Literaturverzeichnis

  • 1 Brodner G., Mertes N., Buerkle H., Marcus A. M., Aken H. Van. Acute pain management: Analysis, implications and consequences after prospective experience with 6349 surgical patients.  Eur.J.Anaesthesiol. 2000;  17 566-575
  • 2 Brodner G., Scherer R., Aken H. Van. Continuous spinal anaesthesia or continuous epidural anaesthesia for postoperative pain control after hip replacement.  Eur.J.Anaesthesiol. 2000;  17 402-403
  • 3 Simanski C., Lefering R., Paffrath T., Riess P., Yucel N., Maegele M., Thusing C, Neugebauer E. Postoperative pain relief is an important factor for the patients' selection of a clinic. results of an anonymous survey.  Schmerz. 2006;  20 327-333
  • 4 Tryba M. Epidural regional anesthesia and low molecular heparin.  Pro. Anasthesiol.Intensivmed.Notfallmed.Schmerzther. 1993;  28 179-181
  • 5 Vandermeulen E., Gogarten W., Aken H. Van. Risks and complications following peridural anesthesia.  Anaesthesist. 1997;  46 179-86
  • 6 Wulf H. Epidural anaesthesia and spinal haematoma.  Can.J.Anaesth. 1996;  43 1260-1271
  • 7 Moen V., Dahlgren N., Irestedt L. Severe neurological complications after central neuraxial blockades in sweden 1990-1999.  Anesthesiology. 2004;  101 950-959
  • 8 Ruppen W., Derry S., McQuay H., Moore A. R.. Incidence of epidural hematoma, infection, and neurologic injury in obstetric patients with epidural analgesia/anesthesia.  Anesthesiology. 2006;  105 394-399
  • 9 Schroeder R. D.. Statistics: Detecting a rare adverse drug reaction using spontaneous reports.  Reg.Anesth.Pain Med. 1998;  23 183-189
  • 10 Belinchon M. J., Campos J., Merino J., Gallego M. J., Barcia C. Y.. Chronic spontaneous lumbar epidural hematoma.  Neurocirugia (Astur). 2005;  16 533-536
  • 11 Gerlif C., Myrtue S. G.. Atypical site of epidural hematoma-after epidural analgesia.  Ugeskr.Laeger. 1994;  156 7231-7232
  • 12 Hsieh F. C., Lin J. H., Chen T. K., Foo P. N., Te L. A.. Acute spontaneous cervical spinal epidural hematoma with hemiparesis as the initial presentation.  Eur.J.Emerg.Med. 2006;  13 36-38
  • 13 Ravi D., Dwarakanath S., Satish R., Gopal S., Venkataramana K. N.. Spontaneous spinal extradural hematomas.  J.Clin.Neurosci. 2006;  13 269-272
  • 14 Macintyre E. P., Power I., Schug A. S.. et al. . Acute pain management: Scientific evidence. 2005; 
  • 15 Liu S. S., Warren T. D., Wu L. C., Ballantyne C. J., Ginsberg B., Rathmell P. J., Rosenquist W. R., Viscusi R. E.. A lovely idea: Forming an ASRA acute postoperative pain (AcutePOP) database.  Reg.Anesth.Pain Med. 2006;  31 291-293
  • 16 Horlocker T. T., Wedel J. D.. Neurologic complications of spinal and epidural anesthesia.  Reg.Anesth.Pain Med. 2000;  25 83-98
  • 17 Gogarten W., Aken H. Van, Wulf H., Klose R., Vandermeulen E., Harenberg J. Para-spinal regional anesthesia and prevention of thromboembolism/anticoagulation. recommendations of the german society of anesthesiology and intensive care medicine, october 1997.  Urologe A. 1998;  37 347-351
  • 18 Awad N. J., Kebaish M. K., Donigan J., Cohen B. D., Kostuik P. J.. Analysis of the risk factors for the development of post-operative spinal epidural haematoma.  J.Bone Joint Surg.Br. 2005;  87 1248-1252
  • 19 Gogarten W.. The influence of new antithrombotic drugs on regional anesthesia.  Curr.Opin.Anaesthesiol. 2006;  19 545-550
  • 20 DGAI.. Rückenmarksnahe regionalanästhesien und thromboembolieprophylaxe / antithrombotische medikation
  • 21 Burger W., Chemnitius M. J., Kneissl D. G., Rucker G.. Low-dose aspirin for secondary cardiovascular prevention - cardiovascular risks after its perioperative withdrawal versus bleeding risks with its continuation - review and meta-analysis.  J.Intern.Med. 2005;  257 399-414
  • 22 Horlocker T. T., Bajwa H. Z., Ashraf Z., Khan S., Wilson L. J., Sami N., Peeters-Asdourian C., Powers A. C., Schroeder R. D., Decker A. P., Warfield A. C.. Risk assessment of hemorrhagic complications associated with nonsteroidal antiinflammatory medications in ambulatory pain clinic patients undergoing epidural steroid injection.  Anesth.Analg.. 2005;  95 1691-7
  • 23 Vandermeulen P. E., Aken H. Van, Vermylen J. Anticoagulants and spinal-epidural anesthesia.  Anesth.Analg. 1994;  79 1165-1177
  • 24 Renck H. Neurological complications of central nerve blocks.  Acta Anaesthesiol.Scand. 1995;  39 859-868
  • 25 Daentzer D., Boker K. D.. Spontaneous spinal hemorrhage. outcome after surgical therapy of epidural hematomas.  Nervenarzt. 2000;  71 116-122
  • 26 Warrenburg P. van de B., Wesseling P., Leyten H. Q., Boerman H. R.. Myelopathy due to spinal epidural abscess without cord compression: A diagnostic pitfall.  Clin.Neuropathol. 2004;  23 102-106
  • 27 Reihsaus E., Waldbaur H., Seeling W.. Spinal epidural abscess: A meta-analysis of 915 patients.  Neurosurg.Rev.. 2000;  23 175-204
  • 28 Grewal S., Hocking G., Wildsmith A. J.. Epidural abscesses.  Br.J.Anaesth. 2006;  96 292-302
  • 29 Kindler C., Seeberger M., Siegemund M., Schneider M.. Extradural abscess complicating lumbar extradural anaesthesia and analgesia in an obstetric patient.  Acta Anaesthesiol.Scand. 1996;  40 858-861
  • 30 Wang S. J., Fellows G. D., Vakharia S., Rosenbaum E. A., Thomas S. P.. Epidural abscess-early magnetic resonance imaging detection and conservative therapy.  Anesth.Analg. 1996;  82 1069-1071
  • 31 Kee D. W., Jones R. M., Thomas P., Worth J. R.. Extradural abscess complicating extradural anaesthesia for caesarean section.  Br.J.Anaesth. 1992;  69 647-652
  • 32 Bauer M., Knippenberger H., Kubli F., Fournier D. von, Radacic A., Mehringer R.. The bacterial contamination of epidural catheters with areobe and anaerobe germs in obstetrics (author's transl).  Geburtshilfe Frauenheilkd. 1979;  39 1054-1056
  • 33 Darouiche O. R.. Spinal epidural abscess.  N.Engl.J.Med. 2006;  355 2012-2020
  • 34 Hlavin L. M., Kaminski J. H., Ross S. J., Ganz E.. Spinal epidural abscess: A ten-year perspective.  Neurosurgery. 1990;  27 177-184
  • 35 Sorensen P.. Spinal epidural abscesses: Conservative treatment for selected subgroups of patients.  Br.J.Neurosurg. 2003;  17 513-518
  • 36 Khanna K. R., Malik M. G., Rock P. J., Rosenblum L. M.. Spinal epidural abscess: Evaluation of factors influencing outcome.  Neurosurgery. 1996;  39 958-964
  • 37 Curry Jr T. W., Hoh L. B., Amin-Hanjani S., Eskandar N. E.. Spinal epidural abscess: Clinical presentation, management, and outcome.  Surg.Neurol.. 2005;  63 364-71
  • 38 Torgovnick J., Sethi N., Wyss J.. Spinal epidural abscess: Clinical presentation, management and outcome (curry WT, hoh BL, hanjani SA, et al. surg neurol 2005;63:364-71).  Surg.Neurol. 2005;  64 279
  • 39 Sapico L. F.. Microbiology and antimicrobial therapy of spinal infections.  Orthop.Clin.North Am. 1996;  27 9-13
  • 40 Rigamonti D., Liem L., Sampath P., Knoller N., Namaguchi Y., Schreibman L. D., Sloan A. M., Wolf A., Zeidman S.. Spinal epidural abscess: Contemporary trends in etiology, evaluation, and management.  Surg.Neurol.. 1999;  52 189-96
  • 41 Sampath P., Rigamonti D.. Spinal epidural abscess: A review of epidemiology, diagnosis, and treatment.  J.Spinal Disord. 1999;  12 89-93
  • 42 Horlocker T. T., Wedel J. D.. Regional anesthesia in the immunocompromised patient.  Reg.Anesth.Pain Med. 2006;  31 334-345
  • 43 Wedel J. D., Horlocker T. T.. Regional anesthesia in the febrile or infected patient.  Reg.Anesth.Pain Med. 2006;  31 324-333
  • 44 Auroy Y., Benhamou D., Bargues L., Ecoffey C., Falissard B., Mercier J. F., Bouaziz H., Samii K.. Major complications of regional anesthesia in france: The SOS regional anesthesia hotline service.  Anesthesiology. 2002;  97 1274-1280
  • 45 Baer T. E.. Post-dural puncture bacterial meningitis.  Anesthesiology. 2006;  105 381-93
  • 46 Empfehlungen zur prävention und kontrolle katheter-assoziierter harnwegsinfektionen. RKI. 1999
  • 47 Mann J. T., Orlikowski E. C., Gurrin C. L., Keil D. A.. The effect of the biopatch, a chlorhexidine impregnated dressing, on bacterial colonization of epidural catheter exit sites.  Anaesth.Intensive Care. 2001;  29 600-603
  • 48 Brooks K., Pasero C., Hubbard L., Coghlan H. R.. The risk of infection associated with epidural analgesia.  Infect.Control Hosp.Epidemiol. 1995;  16 725-728
  • 49 Niesel C. H., Aken H. Van. Lokalanästhesie, regionalanästhesie, regional schmerztherapie. Stuttgart:Georg Thieme Verlag 2003
  • 50 Knudsen K., Beckman M. Suurkula, Blomberg S., Sjovall J., Edvardsson N.. Central nervous and cardiovascular effects of i.v. infusions of ropivacaine, bupivacaine and placebo in volunteers.  Br.J.Anaesth. 1997;  78 507-514
  • 51 Chang H. D., Ladd A. L., Copeland S., Iglesias A. M., Plummer L. J., Mather E. L.. Direct cardiac effects of intracoronary bupivacaine, levobupivacaine and ropivacaine in the sheep.  Br.J.Pharmacol. 2001;  132 649-658
  • 52 Graf M. B., Martin E., Bosnjak J. Z., Stowe F. D.. Stereospecific effect of bupivacaine isomers on atrioventricular conduction in the isolated perfused guinea pig heart.  Anesthesiology. 1997;  86 410-419
  • 53 Graf M. B., Abraham I., Eberbach N., Kunst G., Stowe F. D., Martin E.. Differences in cardiotoxicity of bupivacaine and ropivacaine are the result of physicochemical and stereoselective properties.  Anesthesiology. 2002;  96 1427-1434
  • 54 Valenzuela C., Snyders J. D., Bennett B. P., Tamargo J., Hondeghem M. L.. Stereoselective block of cardiac sodium channels by bupivacaine in guinea pig ventricular myocytes.  Circulation. 1995;  92 3014-3024
  • 55 Naguib M., Magboul M. M., Samarkandi H. A., Attia M.. Adverse effects and drug interactions associated with local and regional anaesthesia.  Drug Saf. 1998;  18 221-250
  • 56 Scott B. D., Hibbard M. B.. Serious non-fatal complications associated with extradural block in obstetric practice.  Br.J.Anaesth. 1990;  64 537-541
  • 57 Auroy Y., Narchi P., Messiah A., Litt L., Rouvier B., Samii K.. Serious complications related to regional anesthesia: Results of a prospective survey in france.  Anesthesiology. 1997;  87 479-486
  • 58 Corcoran W., Butterworth J., Weller S. R., Beck C. J., Gerancher C. J., Houle T. T., Groban L.. Local anesthetic-induced cardiac toxicity: A survey of contemporary practice strategies among academic anesthesiology departments.  Anesth.Analg. 2006;  103 1322-1326
  • 59 Mulroy F. M.. Systemic toxicity and cardiotoxicity from local anesthetics: Incidence and preventive measures.  Reg.Anesth.Pain Med. 2002;  27 556-561
  • 60 Benninghoff A., Drenckhahn D., Zenker W.. Anatomie - niere, reproduktionsorgane, endokrine drüsen, nervensystem, sinnesorgane, Haut. Heidelberg:Urban und Fischer 1994
  • 61 Gristwood W. R., Greaves L. J.. Levobupivacaine: A new safer long acting local anaesthetic agent.  Expert Opin.Investig.Drugs. 1999;  8 861-876
  • 62 Karch B. S.. Cocaine cardiovascular toxicity.  South.Med.J. 2005;  98 794-799
  • 63 Pozner N. C., Levine M., Zane R.. The cardiovascular effects of cocaine.  J.Emerg.Med. 2005;  29 173-178
  • 64 Royse F. C., Royse G. A.. The myocardial and vascular effects of bupivacaine, levobupivacaine, and ropivacaine using pressure volume loops.  Anesth.Analg.. 2005;  101 679-87
  • 65 Velasquez M. E., Anand C. R., Newman 3rd P. W., Richard S. S., Glancy L. D.. Cardiovascular complications associated with cocaine use.  J.La.State Med.Soc.. 2004;  156 302-10
  • 66 Bigger Jr T. J., Mandel J. W.. Effect of lidocaine on conduction in canine purkinje fibers and at the ventricular muscle-purkinje fiber junction.  J.Pharmacol.Exp.Ther. 1970;  172 239-254
  • 67 Moller R., Covino G. B.. Cardiac electrophysiological properties of bupivacaine and lidocaine compared with those of ropivacaine, a new amide local anesthetic.  Anesthesiology. 1990;  72 322
  • 68 Feldmann S. H., Arthur R. G., Covino G. B.. Comparative systemic toxicity of convulsant and supraconvulsant doses of intravenous ropivacaine, bupivacaine and lidocaine in the conscious dog.  Anesth Analg. 1989;  69 794
  • 69 Polley S. L., Columb O. M., Naughton N. N., Wagner S. D., Ven J. van de C.. Relative analgesic potencies of ropivacaine and bupivacaine for epidural analgesia in labor: Implications for therapeutic indexes.  Anesthesiology. 1999;  90 944-950
  • 70 Ben P. Driss, Dubreuil M., Tueux O., Dabadie P., Erny P.. Effects of bupivacaine and lidocaine on mitochondrial respiration and ATP synthesis.  Ann.Fr.Anesth.Reanim.. 1989;  8
  • 71 Graf M. B.. The cardiotoxicity of local anesthetics: The place of ropivacaine.  Curr.Top.Med.Chem. 2001;  1 207-214
  • 72 Zhang S., Yao S., Li Q. Effects of ropivacaine and bupivacaine on rabbit myocardial energetic metabolism and mitochondria oxidation.  J.Huazhong Univ.Sci.Technolog Med.Sci.. 2003;  23 178-9
  • 73 Groban L., Butterworth J.. Lipid reversal of bupivacaine toxicity: Has the silver bullet been identified?.  Reg.Anesth.Pain Med. 2003;  28 167-169
  • 74 Broughton A., Grant O. A., Starmer F. C., Klinger K. J., Stambler S. B., Strauss C. H.. Lipid solubility modulates pH potentiation of local anesthetic block of vmax reactivation in guinea pig myocardium.  Circ.Res. 1984;  55 513-523
  • 75 Weinberg L. G., VadeBoncouer T., Ramaraju A. G., Garcia-Amaro F. M., Cwik J. M.. Pretreatment or resuscitation with a lipid infusion shifts the dose-response to bupivacaine-induced asystole in rats.  Anesthesiology. 1998;  88 1071-1075
  • 76 Weinberg L. G., Ripper R., Murphy P., Edelman B. L., Hoffman W., Strichartz G., Feinstein L. D.. Lipid infusion accelerates removal of bupivacaine and recovery from bupivacaine toxicity in the isolated rat heart.  Reg.Anesth.Pain Med. 2006;  31 296-303
  • 77 Weinberg G., Ripper R., Feinstein L. D., Hoffman W.. Lipid emulsion infusion rescues dogs from bupivacaine-induced cardiac toxicity.  Reg.Anesth.Pain Med. 2003;  28 198-202
  • 78 Weinberg G.. Lipid infusion resuscitation for local anesthetic toxicity: Proof of clinical efficacy.  Anesthesiology. 2006;  105 7-8
  • 79 Rosenblatt A. M., Abel M., Fischer W. G., Itzkovich J. C., Eisenkraft B. J.. Successful use of a 20 % lipid emulsion to resuscitate a patient after a presumed bupivacaine-related cardiac arrest.  Anesthesiology. 2006;  105 217-218
  • 80 Litz J. R., Popp M., Stehr N. S., Koch T.. Successful resuscitation of a patient with ropivacaine-induced asystole after axillary plexus block using lipid infusion.  Anaesthesia. 2006;  61 800-801
  • 81 Picard J., Meek T., Weinberg G., Hertz P.. Lipid emulsion for local anaesthetic toxicity.  Anaesthesia. 2006;  61 1116-1117
  • 82 Weinberg L. G.. In defence of lipid resuscitation.  Anaesthesia. 2006;  61 807-808
  • 83 Weinberg G.. Lipid rescue: Caveats and recommendations for the „silver bullet”.  Reg.Anesth.Pain Med. 2004;  29 74

Prof. Dr. med. Esther M. Pogatzki-Zahn

Email: pogatzki@anit.uni-muenster.de

Dr. Manuel Wenk

Email: manuelwenk@uni-muenster.de