Nervenschäden bei Regionalanästhesie – Umgang mit in situ verbliebenen wirbelsäulennahen Katheterfragmenten

Zusammenfassung

Eine aufgrund ihres seltenen Auftretens in der Literatur wenig beschriebene Komplikation ist der Verbleib eines Katheterfragments im neuraxialen Raum. Aus den Antworten eines Fragebogens an Anästhesisten, Neurochirurgen, Orthopäden und Unfallchirurgen wurde versucht, eine Expertenmeinung als Handlungsanweisung zu generieren:

Bei Kindern besteht eine sofortige Operationsindikation. Beim asymptomatischen Erwachsenen kann ohne Antibiotikaprophylaxe zugewartet werden. Bei Symptomatik sollte ein Dünnschicht-Computertomogramm oder eine Durchleuchtung erfolgen. Haupt-indikationen für eine Operation sind neurologische Ausfälle, Liquorverlustsymptomatik, Infektionen, Schmerzen und lokale Beschwerden. Relative Indikationen sind starke Schmerzen, Infektion und gesicherte intrathekale Lage.

Das operative Vorgehen sieht die Lagerung in Bauchlage und das Aufsuchen des Fragments in Allgemeinanästhesie über die Eintrittsstelle vor. Ist die Eintrittspforte nicht mehr lokalisierbar, soll eine mediane Inzision gewählt werden. Die Verwendung eines Operationsmikroskops und die Durchführung der Chirurgie durch einen Neurochirurgen bzw. erfahrenen Wirbelsäulenchirurgen wird angeraten.

Abstract

The rupture of a catheter near the spine is rare. There are no evidence-based guidelines for diagnosis and therapy. Opinions derived from German anesthesiologists, neurosurgeons, orthopaedics and trauma surgeons are:

Infants should have immediate surgery. In an asymptomatic adult, the catheter fragment does not require removal surgery. Antibiotic prophylaxis is not necessary. If symptomatic, the catheter fragment should be localized by a thin slice computed tomography or fluoroscopy. Otherwise surgical exploration is indicated. Direct surgery is recommended for cases with neurological symptoms, infections, loss of spinal fluid, pain and local discomfort. Relative indications for surgery are severe pain, tissue infection and intrathecal localization of the fragment.

Surgery should be performed in prone position and under general anesthesia. Starting at the entry wound, the surgical access should be microsurgical and preferably by a neurosurgeon. If the entry is not detectable, a midline incision is suggested.

Schlüsselwörter:

Umfrage - Expertenmeinung - Katheterfragment - Entfernung - neuraxial

Key words:

questionnaire - expert opinion - neuraxial catheter - fragment - removal

• Literatur

• 1 Dounas M, Peillon P, Lebonhomme JJ, Guittard Y. Difficulties in the removal and rupture of a peridural catheter. Ann Fr Anesth Reanim 2002; 21: 600-602
• 2 Escobar Ayllon MJ, Tormo Belda M, Marco J, Martinez C. Accidental rupture of a caudal catheter in the paravertebral space. Rev Esp Anestesiol Reanim 2011; 58: 400-400
• 3 Ferguson S, Brighouse D, Valentine S. An unusual complication following combined spinal-epidural anaesthesia for caesarean section. Int J Obstet Anesth 1997; 6: 190-193
• 4 Gehan G, De Mongolfier R, Coulon JM et al. Rupture of an epidural catheter, becoming of the retained fragment. About one case. Ann Fr Anesth Reanim 2010; 29: 403-404
• 5 Olivar H, Bramhall JS, Rozet I et al. Subarachnoid lumbar drains: a case series of fractured catheters and a near miss. Can J Anaesth 2007; 54: 829-834
• 6 Asai T, Yamamoto K, Hirose T et al. Breakage of epidural catheters: a comparison of an arrow reinforced catheter and other nonreinforced catheters. Anesth Analg 2001; 92: 246-248
• 7 Ates Y, Yucesoy CA, Unlu MA et al. The mechanical properties of intact and traumatized epidural catheters. Anesth Analg 2000; 90: 393-399
• 8 Castellani C, Schalamon J, Saxena AK, Hoellwarth ME. Early complications of the Nuss procedure for pectus excavatum: a prospective study. Pediatr Surg Int 2008; 24: 659-666
• 9 Collier C. Epidural catheter breakage: a possible mechanism. Int J Obstet Anesth 2000; 9: 87-93
• 10 Demiraran Y, Yucel I, Erdogmus B. Subcutaneous effusion resulting from an epidural catheter fragment. Br J Anaesth 2006; 96: 508-509
• 11 Fischer R. Epidural conduction device fractures and complications of retained fragments. AANA J 2008; 76: 37-40
• 12 Hamid M, Qamar ul hoda M, Samad K. Effectiveness of premature epidural catheter termination as a quality indicator in a developing country. Eur J Anaesthesiol 2011; 27: 637-641
• 13 Hobaika AB. Breakage of epidural catheters: etiology, prevention, and management. Rev Bras Anestesiol 2008; 58: 227-233
• 14 Kim P, Meyer U, Schupfer G et al. Tensile strength decreases and perfusion pressure of 3-holed polyamide epidural catheters increases in long-term epidural infusion. Reg Anesth Pain Med 2011; 36: 151-155
• 15 Lee YH, Hwang HY, Sim WS et al. Breakage of a thoracic epidural catheter during its removal – A case report. Korean J Anesthesiol 2011; 58: 569-572
• 16 Mitra R, Fleischmann K. Management of the sheared epidural catheter: is surgical extraction really necessary?. J Clin Anesth 2007; 19: 310-314
• 17 Nishio I, Sekiguchi M, Aoyama Y et al. Decreased tensile strength of an epidural catheter during its removal by grasping with a hemostat. Anesth Analg 2001; 93: 210-212
• 18 Sah N, Finegold H. Breakage of epidural catheters in two parturients. Can J Anaesth 2003; 50: 619-620
• 19 Sbardelotto C, Yoshimi MM, Pereira Rda R, de Castro RA. Breakage of a catheter in the epidural space. Rev Bras Anestesiol 2008; 58: 643-650
• 20 Schummer W, Schummer C. Another cause of epidural catheter breakage?. Anesth Analg 2002; 94: 233-233
• 21 Ugboma S, Au-Truong X, Kranzler LI et al. The breaking of an intrathecally-placed epidural catheter during extraction. Anesth Analg 2002; 95: 1087-1089
• 22 Vasdev G, Trentman T, Leicht C. The use of an electronic scale in preventing epidural catheter breakage. Int J Obstet Anesth 1993; 2: 241-242
• 23 Wadhwa R, Sharma S, Poddar D. Pleural puncture with thoracic epidural: A rare complication?. Indian J Anaesth 2011; 55: 163-166
• 24 Guppy KH, Silverthorn JW, Akins PT. Subarachnoid hemorrhage due to retained lumbar drain. J Neurosurg Spine 2011; 15: 641-644
• 25 Sakuma N, Hori M, Suzuki H et al. A sheared off and sequestered epidural catheter: a case report. Masui 2004; 53: 198-200
• 26 Napolitano LM, Kurek S, Luchette FA et al. Clinical practice guideline: red blood cell transfusion in adult trauma and critical care. J Trauma 2009; 67: 1439-1442
• 27 Staats PS, Stinson MS, Lee RR. Lumbar stenosis complicating retained epidural catheter tip. Anesthesiology 1995; 83: 1115-1118
• 28 Chen P, Gandhi SD, Iqbal Z et al. An unusual complication of lumbar subarachnoid drainage catheter placement in a patient undergoing endovascular stent repair of a thoracic aortic aneurysm. J Cardiothorac Vasc Anesth 2007; 21: 763-765
• 29 Merk H, Kramer R, Baltzer AW, Liebau C. Microsurgical lumbar intervertebral disk operation. Technique and complications. Orthopade 1999; 28: 593-597
• 30 Corbonnois G, O'Neill T, Brabis-Henner A et al. Unrecognized dural puncture during epidural analgesia in obstetrics later confirmed by brain imaging. Ann Fr Anesth Reanim 2010; 29: 584-588