Klumpner Thomas T, Toledo Paloma, Wong Cynthia A, Farrer Jason R
Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
Department of Anesthesiology, University of Michigan, 1H247 University Hospital, 1500 East Medical Center Drive, Ann Arbor, MI, 48109-5048, USA.
Can J Anaesth. 2016 Apr;63(4):475-9. doi: 10.1007/s12630-015-0540-7. Epub 2015 Dec 3.
Some labouring women with neuraxial labour analgesia experience severe upper back pain, typically between the scapulae. This pain may complicate management of neuraxial analgesia/anesthesia, and it may also have important implications for the mode of delivery. This case series describes the clinical course and management of three patients who developed interscapular pain associated with neuraxial labour analgesia.
Neuraxial labour analgesia was initiated in all patients with a combined spinal-epidural technique and maintained via patient-controlled epidural analgesia. Two patients were nulliparous. One patient experienced interscapular pain during initiation of epidural anesthesia for Cesarean delivery after 19 hr of maintenance of labour analgesia with local anesthetic/opioid solution. The other two patients experienced interscapular pain during routine maintenance of epidural labour analgesia. In two patients, the epidural space was identified using loss of resistance to air. Another patient recalled experiencing interscapular pain with her prior labour epidural. Management of these patients included decreasing the epidural infusion rate, increasing the concentration of local anesthetic in the epidural infusion solution, administration of epidural opioids, and replacement of the epidural catheter. All patients eventually experienced relief of their interscapular pain.
While little is understood about the etiology of this unique anesthetic complication, it may have important clinical consequences, including inadequate analgesia, inability to provide timely epidural anesthesia, and an increased risk of Cesarean delivery. Future work should characterize at-risk patients, delineate effective treatment strategies, and identify any associated long-term consequences.
一些接受椎管内分娩镇痛的产妇会经历严重的上背部疼痛，通常位于肩胛骨之间。这种疼痛可能会使椎管内镇痛/麻醉的管理复杂化，也可能对分娩方式产生重要影响。本病例系列描述了三名出现与椎管内分娩镇痛相关的肩胛间疼痛患者的临床过程及管理情况。
所有患者均采用腰麻-硬膜外联合技术开始椎管内分娩镇痛，并通过患者自控硬膜外镇痛维持。两名患者为初产妇。一名患者在用局部麻醉药/阿片类溶液维持分娩镇痛19小时后，在剖宫产硬膜外麻醉开始时出现肩胛间疼痛。另外两名患者在硬膜外分娩镇痛的常规维持过程中出现肩胛间疼痛。两名患者通过空气阻力消失法确定硬膜外间隙。另一名患者回忆起她上次分娩硬膜外镇痛时也经历过肩胛间疼痛。对这些患者的管理措施包括降低硬膜外输注速率、提高硬膜外输注溶液中局部麻醉药的浓度、给予硬膜外阿片类药物以及更换硬膜外导管。所有患者最终肩胛间疼痛均得到缓解。
虽然对这种独特麻醉并发症的病因了解甚少，但它可能会产生重要的临床后果，包括镇痛不足、无法及时提供硬膜外麻醉以及剖宫产风险增加。未来的研究应明确高危患者特征，确定有效的治疗策略，并识别任何相关的长期后果。
