Brazilian Journal of Anesthesiology
https://bjan-sba.org/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
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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

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