Litz Rainer J, Vicent Oliver, Wiessner Diana, Heller Axel R
Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Dresden, Germany.
Reg Anesth Pain Med. 2004 Jan-Feb;29(1):60-4. doi: 10.1016/j.rapm.2003.09.013.
This case report describes an unusual cause of misplacement of an indwelling catheter in the subarachnoid space after primary psoas compartment block in a patient undergoing total knee arthroplasty.
A 67-year-old woman presenting for total knee joint replacement received a combination of continuous psoas compartment block and sciatic nerve block. Neurostimulation and additional ultrasound guidance were used for identification of the lumbar plexus. After elicitation of a quadriceps motor response, a negative aspiration test, and an uneventful test dose, 20 mL ropivacaine 0.375% and 20 mL mepivacaine 1% were injected. Despite difficult ultrasound conditions because of intestinal air, local anesthetic spread was observed paravertebrally at the medial border of the psoas muscle as usual. A catheter was then advanced 7 cm through the insulated directional puncture needle. An additional sciatic nerve block was performed by using Labat's approach. Ten minutes after injection unilateral sensory block was noted and surgery was started. After uneventful surgery, bilateral sensory block to the T4 level and complete motor block in both lower limbs was detected. A second aspiration test was negative, and an epidural block was suspected. For verification of the catheter tip location, a computed tomography scan with contrast dye was performed revealing catheter placement in the subarachnoid space. The catheter was removed and showed a kink about 7 cm from the tip. After regression of the neuraxial block, lumbar plexus block persisted for another 2 hours.
An additional test dose via the catheter is recommended if the indwelling catheter is inserted after injection of the local anesthetics through the puncture needle. If epidural anesthesia occurs, an x-ray of the catheter is advisable because negative aspiration via catheter does not rule out subarachnoid catheter location.
本病例报告描述了全膝关节置换术患者在初次腰大肌间隙阻滞术后蛛网膜下腔留置导管误置的罕见原因。
一名67岁女性因全膝关节置换术接受连续腰大肌间隙阻滞和坐骨神经阻滞联合麻醉。使用神经刺激器并辅以超声引导来识别腰丛。引出股四头肌运动反应、回抽试验阴性且试验剂量注射顺利后，注入20 mL 0.375%罗哌卡因和20 mL 1%甲哌卡因。尽管因肠道气体干扰导致超声条件不佳，但仍如常观察到局部麻醉药在腰大肌内侧缘椎旁扩散。随后通过绝缘定向穿刺针将一根导管推进7 cm。采用拉巴特法进行了额外的坐骨神经阻滞。注射后10分钟出现单侧感觉阻滞，手术开始。手术顺利完成后，检测到双侧T4水平感觉阻滞及双下肢完全运动阻滞。再次回抽试验阴性，怀疑发生了硬膜外阻滞。为核实导管尖端位置，进行了含造影剂的计算机断层扫描，显示导管置入蛛网膜下腔。导管取出后，尖端约7 cm处出现一处弯折。神经轴阻滞消退后，腰丛阻滞又持续了2小时。
如果在通过穿刺针注射局部麻醉药后插入留置导管，建议通过导管追加试验剂量。如果发生硬膜外麻醉，建议对导管进行X线检查，因为通过导管回抽阴性并不能排除导管位于蛛网膜下腔的情况。
