Second Department of Anesthesiology, "Attikon" University Hospital, National and Kapodistrian University of Athens, 1 Rimini Str., 12461, Athens, Greece.
Department of Thoracic Surgery, "Attikon" University Hospital, National and Kapodistrian University of Athens, 1 Rimini Str., 12461, Athens, Greece.
J Med Case Rep. 2024 May 29;18(1):263. doi: 10.1186/s13256-024-04588-y.
Pneumomediastinum and pneumorrachis are rare complications following epidural analgesia, that can either be asymptomatic or rarely can produce mild to moderate severity symptoms. Most reported cases regarding the presentation of these two entities with epidural analgesia concern asymptomatic patients, however there are cases reporting post-dural puncture headache and respiratory manifestations.
We present a case where a combined lumbar epidural and spinal anesthesia was performed using the loss of resistance to air technique (LOR), on a 78-year-old Greek (Caucasian) male undergoing a total hip replacement. Despite being hemodynamically stable throughout the operation, two hours following epidural analgesia the patient manifested a sudden drop in blood pressure and heart rate that required the administration of adrenaline to counter. Pneumomediastinum, pneumorrachis and paravertebral soft tissue emphysema were demonstrated in a Computed Tomography scan. We believe that injected air from the epidural space and surrounding tissues slowly moved towards the mediastinum, stimulating the para-aortic ganglia causing parasympathetic stimulation and therefore hypotension and bradycardia.
Anesthesiologists should be aware that epidural analgesia using the LOR to technique injecting air could produce a pneumomediastinum and pneumorrachis, which in turn could produce hemodynamic instability via parasympathetic stimulation.
在硬膜外镇痛后，会出现气胸和纵隔积气，这是罕见的并发症，可能无症状，也可能出现轻度至中度严重症状。大多数关于这两种情况与硬膜外镇痛相关的报告涉及无症状患者，但也有报告称与硬膜穿破后头痛和呼吸表现相关的病例。
我们报告了一例 78 岁的希腊（白种人）男性在接受全髋关节置换术时，使用空气阻力消失技术（LOR）进行联合腰硬麻醉的病例。尽管在整个手术过程中血流动力学稳定，但在硬膜外镇痛后两小时，患者出现血压和心率突然下降，需要给予肾上腺素进行对抗。胸部 CT 扫描显示纵隔积气、纵隔积气和椎旁软组织气肿。我们认为，来自硬膜外腔和周围组织的注入空气会缓慢向纵隔移动，刺激腹主动脉旁神经节，引起副交感神经刺激，从而导致低血压和心动过缓。
麻醉师应该意识到，使用 LOR 技术向硬膜外腔注射空气可能会导致气胸和纵隔积气，进而通过副交感神经刺激导致血流动力学不稳定。
