Brazilian Journal of Anesthesiology
https://bjan-sba.org/article/doi/10.1590/S0034-70942004000100011
Brazilian Journal of Anesthesiology
Clinical Information

Abscesso peridural após analgesia controlada pelo paciente por via peridural: relato de caso

Epidural abscess after patient-controlled epidural analgesia: case report

Múcio Paranhos de Abreu; Roberto de Góis Deda; Luis Henrique Cangiani; Hernando Mauro Diógenes Aquino; Jair Ortiz

http://dx.doi.org/10.1590/S0034-70942004000100011 Braz J Anesthesiol, vol.54, n1, p.78-83, 2004
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Resumo

JUSTIFICATIVA E OBJETIVOS: A analgesia peridural é freqüentemente utilizada para o controle da dor pós-operatória ou para tratamento da dor crônica em pacientes oncológicos. No entanto, não está isenta de complicações. Neste caso, relatamos a ocorrência de abscesso peridural em paciente jovem, hígida, que foi submetida a analgesia peridural em bomba de infusão controlada pela paciente, que apresentou abscesso peridural, sendo necessária descompressão cirúrgica. RELATO DO CASO: Paciente do sexo feminino, 24 anos, 56 kg, 1,65 m, estado físico ASA I, com história de lombalgia e dificuldade de flexão da coxa esquerda, foi submetida à cirurgia para liberação da musculatura posterior do quadril. Três dias após a alta hospitalar retornou ao hospital queixando-se de dor no local da incisão cirúrgica e durante a realização dos exercícios fisioterápicos. Foi internada e programada analgesia controlada pelo paciente (ACP) por via peridural, para possibilitar o tratamento fisioterápico. No centro cirúrgico foi feita sedação por via venosa com midazolam (2,5 mg) e fentanil (25 µg), anti-sepsia da pele e realizada punção peridural no espaço L3-L4. Após dose teste foram injetados ropivacaína a 0,75% (75 mg) e fentanil (100 µg) e passado cateter peridural em sentido cefálico, sem intercorrências. Foi instalada bomba de ACP contendo solução fisiológica a 0,9% (85 ml), bupivacaína a 0,5% (25 mg) e fentanil (500 µg), programada com fluxo constante de 4 ml.h-1 e bolus de 2 ml a cada 20 minutos. No 3º dia a paciente relatou incômodo no local da inserção do cateter, sendo o mesmo retirado. Havia discreta hiperemia no local. Após vinte e dois dias, a paciente retornou ao hospital com dor de grande intensidade na região lombossacra com irradiação para os membros inferiores e limitação dos movimentos. Não havia deficit neurológico ou sinais flogísticos no local da punção ou na ferida operatória. Foi feita hipótese de abscesso peridural e a ressonância nuclear magnética confirmou a presença do mesmo em L3-L4 (2 x 3 cm), realizada laminectomia, a cultura do material mostrou tratar-se de staphilococcus aureus. A paciente evoluiu bem, sem seqüela neurológica. CONCLUSÕES: A analgesia peridural, muitas vezes utilizada para o controle da dor pós-operatória ou da dor crônica, embora muito efetiva, não está livre de complicações, ainda que raras, como o abscesso peridural.

Palavras-chave

ANALGESIA, Pós-Operatória, COMPLICAÇÕES

Abstract

BACKGROUND AND OBJECTIVES: Epidural analgesia is often used to control postoperative pain or to manage chronic pain in oncologic patients. However, it is not free from complications. This case reports a young healthy female patient submitted to epidural analgesia in patient-controlled infusion pump, which developed epidural abscess requiring surgical decompression.
CASE REPORT: Female patient, 24 years of age, 56 kg, 1.65 m, physical status ASA I, with history of low back pain and difficulty to bend left thigh, submitted to posterior hip muscles surgical release. Three days after hospital discharge, patient returned referring pain at surgical incision site and during physical therapy. Patient was admitted to hospital and patient-controlled epidural analgesia (PCA) was prescribed to allow physical therapy. Patient was sedated in the operating room with intravenous midazolam (2.5 mg) and fentanyl (25 µg), skin was disinfected and epidural puncture was performed at L3-L4 interspace. After the test dose, 0.75% ropivacaine (75 mg) and fentanyl (100 µg) were injected and an epidural catheter was inserted in the cephalad direction without intercurrences. PCA pump containing 0.9% saline solution (85 ml), 0.5% bupivacaine (25 mg) and fentanyl (500 µg) was installed, with constant 4 ml.h-1 flow and 2 ml bolus at 20-minute intervals. In the 3rd day, patient referred discomfort at catheter insertion site and catheter was removed. There was mild local hyperemia. Twenty-two days later patient returned to hospital with severe lumbosacral movement-limiting pain irradiating to lower limbs. There were no neurological deficits or flogistic signs at puncture site or surgical wound. The hypothesis was epidural abscess confirmed by MRI at L3-L4 (2 x 3 cm). After laminectomy, material culture has revealed staphylococcus aureus. Patient evolved well without neurological sequelae.
CONCLUSIONS: Epidural analgesia often used to control postoperative or chronic pain, although very effective, is not free from severe, although rare complications, such as epidural abscess.

Keywords

ANALGESIA, Postoperative: patient controlled analgesia; COMPLICATIONS: epidural abscess

References

Wang LP, Hauerber J, Schimidt JF. Incidence of spinal epidural abscess after epidural analgesia. Anesthesiology. 1999;91:1928-1936.

Rygnestad T, Borchgrevink PC, Eide E. Postoperative epidural infusion of morphine and bupivacaine is safe on surgical wards: organization of the treatment, effects and side effects in 2.000 consecutive patients. Acta Anaesthesiol Scand. 1997;41:868-876.

Dahgren N, Törnebrandt K. Neurological complications after anaesthesia: a follow-up of 18000 spinal and epidural anaesthetics performed over three years. Acta Anaesthesiol Scand. 1995;39:872-880.

Strong WE. Epidural abscess associated with epidural catheterization: a rare event?: Report two cases with markedly delayed presentation. Anesthesiology. 1991;74:943-946.

Kindler C, Seeberger M, Siegmund M. Extradural abscess complicating lumbar extradural anaesthesia and analgesia in an obstetric patient. Acta Anaesthesiol Scand. 1996;40:858-861.

Phillips JMG, Stedeford JC, Hartsilver E. Epidural abscess complicating insertion of epidural catheters. Br J Anaesth. 2002;89:778-782.

NganKee WD, Jones MR, Thomas P. Extradural abscess complicating extradural anaesthesia for caesarean section. Br J Anaesth. 1992;69:647-652.

Fine PG, Hare BD, Zahniser JC. Epidural abscess following epidural catheterization in a chronic pain patient: a diagnostic dilemma. Anesthesiology. 1988;69:422-424.

Ernetell M, Holtas S, Norlin K. Magnetic resonance imaging in the diagnosis of spinal epidural abscess. Scand J Infect Dis. 1988;20:323-327.

North JB, Broph BP. Epidural abscess: a hazard of spinal epidural anaesthesia. Aust N Z J Surg.. 1979;49:484-485.

Holt HM, Anderson SS, Anderson O. Infections following epidural catheterization. J Hosp Inf.. 1995;30:253-260.

James FM, George RH, Naiem H. Bacteriological aspects of epidural analgesia. Anesth Analg. 1976;55:187-190.

Radler C, Lass-Flörl C, Puhringer F. Bacterial contamination of needles used for spinal and epidural anaesthesia. Br J Anaesth. 1999;83:657-658.

Dawson SJ, Samll H, Logan MN. Case control study of epidural catheter infection in a district general hospital. Commun Dis Public Health. 2000;3:300-302.

Hlavin ML, Kaminski HJ, Ross JS. A ten year perspective. Neurosurgery. 1990;27:177-184.

Dysart RH, Balakrishnan V. Conservative management of extradural abscess complicating spinal extradural anaesthesia for caesarean section. Br J Anaesth. 1997;78:591-593.

Bengtsson M, Nettelbland H, Sjoberg F. Extradural catheter: related infections in patients with infected cutaneous wounds. Br J Anaesth. 1997;79:668-670.

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