I asked the wise guy who recommended thoracic epidural postoperative analgesia to us what he would do if the spinal cord had been pierced. I had to tease him for a long time so that he would recognize it as possible.
Non-operative epidural analgesia can cause all the complications that intraoperative epidural anesthesia can have, such as single-use, hook and prolonged — with a catheter. It is clear that because of its duration, precautions must be stricter, especially with regard to asepsis. But it may also have specific complications.
SPECIFIC COMPLICATIONS
Too good analgesia can be harmful if the patient needs periodic evaluation of the pain syndrome. Cases have been described in different countries when, against the background of ideal epidural anesthesia, the compartment syndrome with interfascial edema in the injured extremity remained unrecognized in a timely manner, leading to muscle necrosis and even forced amputation. In such cases, long-term epidural anesthesia is considered by many to be contraindicated.
An erroneously injected solution — this complication is found in different countries more and more often, in parallel with the ever-increasing use of long-term epidural analgesia through a catheter. The nursing cannula of this catheter placed on the upper arm is confused with the subclavian or jugular catheter, and the introduction of a wide variety of intravenous solutions into the epidural space is described. Fortunately, it has neko toruyu buffering capacity, and the dura mater is pretty good protects the roots of the spinal cord. Therefore, in most of the cases described, the consequences were limited to the fear of the doctor. But not all complications are described in the literature! Prevention: (1) instructing nurses, especially for epidural analgesia outside the intensive care unit; (2) the inscriptionon the adhesive plaster, which is fixed to the skin of the cannula of the epidural catheter; (3) the old rule cited in the orders of the People’s Commissariat of Health : the name and concentration of the medicine should be read out loud by two people; (4) opening the ampoule or vial only immediately before administration.
Clinical example
In a highly respected Brazilian clinic, which has been widely using caudal anesthesia since the 1960s, the anesthesiologist, when she came to the operating room, saw on the workbench of a boron for caudal anesthesia and an opened bottle of Markain. After introducing the child into anesthesia, she performed a cassual anesthesia (it was planned to remove exostosis on the lower limb). The surgeon came in, removed the exostosis and asked: “Where is my formalin?” – “What is the shape of lin?” – “Yes, the one that I put on your table” … After several years, the child has lower paraplegia and sphincter disorders .
Overdose of intrathecal morphine. Erroneous (due to an incorrect concentration of solutions) subarachnoid injections of fantastically high doses (hundreds of milligrams) of morphine are also described. This led to excitation, dilated pupils, myoclonic convulsions, respiratory disorders, arterial hypotension, and in most patients – to death. Treatment — not the introduction of naloxone, but mechanical ventilation and the quickest possible washout drainage of the subarachnoid space through two catheters: one at the cervical level (heated Ringer’s solution is injected into it), the other at the lumbar level (liquor flows from it).
Since long-term stay of the catheter in the epidural space may cause perforation of the dura mater, with its tip falling into the subarachnoid space, you need to be aware of the possibility of such a complication.
It is clear that the above-described complications can lead to catastrophic consequences even in the operating room and intensive therapy unit. They are all the more dangerous in a regular ward outside the intensive care unit. Therefore, in most of our medical institutions, patients with an epidural catheter are tried to be left in the intensive care unit. If, for reasons of economic efficiency, epidural anesthesia is carried out, as is customary in developed countries, in ordinary departments, the nurses of these departments should receive special training and have appropriate protocols, examples of which are “Recommendations for the management of patients with prolonged epidural analgesia ” .