Elsevier

Acute Pain

Volume 8, Issue 2, June 2006, Pages 83-86
Acute Pain

Case report
Horner's syndrome following thoracic epidural analgesia in children: A report of two cases

https://doi.org/10.1016/j.acpain.2006.05.001Get rights and content

Summary

We report two cases of Horner's syndrome associated with thoracic epidural analgesia in patients undergoing thoracotomy for excision of congenital cystic adenoid malformation (CCAM). We discuss the clinical findings in our cases as well as factors that may have contributed to their appearance. A decision-making algorithm is suggested. Although Horner's syndrome is a benign complication if related to epidural, persisting signs should be studied and other causes ruled out.

Introduction

Bainbridge reported the use of regional anaesthesia in children as early as 1901 [1]. With increasing use in the postoperative setting the incidence of complications has risen, including those that were not obviously related to these techniques. While known to be associated with labour epidurals, Horner's syndrome (HS) as a complication of regional anaesthesia has rarely been reported in children [2], [3], [4]. We report two cases of Horner's syndrome in two infants who underwent surgery for congenital cystic adenomatoid malformation (CCAM) and review the pathways involved and suggest an algorithm for managing the epidural analgesia in these cases.

Section snippets

Case 1

A 17-month 10 kg, ASA II, Hispanic male underwent a right middle lobectomy after being diagnosed 3 months earlier with a right middle CCAM type II. Prior to surgical incision, an 18G Tuohy needle was inserted in the T8–T9 space and an open-end hole epidural catheter inserted 8 cm into the epidural space. Aspiration and gravitational flow revealed no evidence of cerebrospinal fluid or blood. The patient first received a 5 ml bolus of bupivacaine 0.25% with epinephrine 1:200,000 followed by a

Discussion

Horner's syndrome following thoracic epidural analgesia has recently been reported in children with an incidence of 2.6% [2], [3], [4]. These two cases of HS were the only ones seen in our hospital among 99 thoracic epidural procedures (T5–6 to T12-L1) including 9 for thoracotomy for excision of CCAM, performed over the last 18 months, an incidence of 2%. Most reports of Horner's syndrome following epidural blockade in adults have been in pregnant women with lumbar epidural catheters and the

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    Citation Excerpt :

    This complication has been reported in children, with an incidence of 0.3%-2.6%, and did not result in untoward sequelae (Ecoffey et al., 2010; Valois et al., 2006; Zadra & Giusti, 2000). Despite the occurrence of Horner syndrome, we continued analgesia by the epidural route, similar to Valois et al. (2006), Aronson et al. (2000), and Zadra and Giusti (2000), providing an accurate observation of the patient's vital signs and neurologic function. Furthermore, three of our patients had anisocoria, with the left pupil smaller than the right.

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