Abstract
Purpose
The purpose of this report is to emphasise the role of the Acute Pain Service in managing local anaesthetic epidural infusions for postoperative pain management, the importance of vigilant monitoring, and to offer some guidelines to using local anaesthetic epidural infusions.
Clinical features
A 34-yr-old man with long-standing insulin dependent diabetes mellitus underwent a total proctocolectomy for inflammatory bowel disease. A T9–10 epidural catheter was placed pnor to induction of general anaesthesia. Postoperatively, a continuous epidural infusion of fentanyl/bupivacaine was used for postoperative pain management. Total lithotomy time was four hours. On day four he was noted to have complete right sided femoral and left sided lateral femoral cutaneous nerve of thigh neuropathies. A computensed tomography scan and a magnetic resonance imaging excluded a central lesion. Electromyelography confirmed peripheral nerve injuries.
Conclusion
This patient’s neurological deficits were not due to the epidural analgesia. However, epidural infusion of local anaesthetic caused a delay in recognising a potential neurological complication. When using local anaesthetic epidural infusions, it is important to exclude other causes of motor block before attributmg it to the local anaesthetic.
Résumé
Objectif
Ce compte rendu vise à souligner le rôle d’un service de gestion de la douleur aiguë sous l’aspect de la prise en charge des perfusions épidurales d’anesthésiques locaux administrées pour le traitement de la douleur postopératoire; rappeler l’importance d’une surveillance étroite; proposer des lignes de conduite sur l’utilisation des perfusions épidurales d’anesthésiques locaux.
Éléments cliniques
Un homme de 34 ans souffrant d’un diabète insulino-dépendant de longue date subissait une colectomie totale pour une maladie inflammatoire intestinale. Un cathéter épidural était installé à T9–10 avant l’induction de l’anesthésie générale. En postopératoire, une perfusion continue de fentanyl/bu≪vacaïne était mise en marche pour soulager la douleur postopératoire. La position de lithotomie avait été maintenue pendant quatre heures. Le quatrième jour, on décelait des neuropathies graves du nerf fémoral droit et du nerf fémorocutané latéral gauche de la cuisse. La tomographie informatisée et l’imagene par résonance magnétique éliminaient la présence d’une lésion centrale. Lélectromyographie confirmait que les lésions nerveuses étaient pénphénques.
Conclusion
Dans le cas présent, les déficits neurologiques n’étaient pas en rapport avec l’analgésie épidurale. Cependant, la perfusion épidurale d’un anesthésique local a retardé le diagnostic d’une complication neurologique. Avec les perfusions épidurales d’anesthésiques locaux, il est important d’éliminer les autres causes de bloc moteur avant de les attribuer aux anesthésiques.
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Kahn, L. Neuropathies masquerading as an epidural complication. Can J Anaesth 44, 313–316 (1997). https://doi.org/10.1007/BF03015371
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DOI: https://doi.org/10.1007/BF03015371