Marquort H, Grenzer G, Schroeder U
Institut für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Ev.-luth. Diakonissenkrankenhaus Flensburg.
Anaesthesist. 1993 Aug;42(8):501-8.
In the last few years epidural analgesia with bupivacaine and/or opioids has become an important technique in the therapy of postoperative pain. Using bupivacaine only 2-20% of the patients are treated without sufficient success. To ascertain and evaluate the underlying reasons for this, we prospectively investigated 51 patients routinely, and 6 patients with an insufficient analgetic effect from a group of 212 patients, by means of epidurography. All patients were treated mainly with bupivacaine. The observed and documented radiographic data were compared with the individual analgetic results. METHODS. All investigations were performed within 24 h after placing the catheters. The contrast agent was injected under radiographic guidance in two different positions, and the end of the distribution was documented in the anterior-posterior ray path. In group I (n = 26) the catheter position and the distribution of the contrast medium with 3.0 ml iopamidol were documented. In group II (n = 25) the catheter position was documented in the same way, but the distribution was documented for the stepwise-injected contrast medium (3.0 ml + 2.0 ml + 3.0 ml). As a result of these findings we changed our epidural catheter placement concept in the following patients (group III, n = 212), and performed radiographic examinations in patients with a therapy failure only (group IIIa, n = 6). Instead of placing the catheter postoperatively mostly lumbal in a lateral position, we now placed them preoperatively, in the sitting position, as near as possible to the centre of the segments to be treated. RESULTS. Only 27 patients demonstrated an ideal catheter position and a typical contrast medium distribution. Three of these patients still could not be treated successfully. In 12 patients the spread of the contrast medium was inhomogeneous, and in 5 patients the contrast medium was found on one side of the epidural space only. Half of these 17 patients (n = 9) needed supplementary therapy. Surprisingly, 4 of 8 patients with a paraepidural catheter position were treated with success. DISCUSSION. Effective bupivacaine therapy by epidural catheter injections constitutes no striking evidence for a correct epidural catheter position. If the catheter lies in the epidural space, the actual therapeutic effect of bupivacaine therapy is determined mainly by the distribution of the substance. The epidural position of the catheter--central or lateral in the epidural space--seems, however, not to be particularly important. If high-quality analgesia is to be achieved with bupivacaine alone, or in combination with an opioid, the catheter should usually be placed near to, or better into the centre of the segments to be treated. The results demonstrate that in the case of failure of epidural catheter therapy, epidurographic examinations are very helpful in ascertaining and evaluating the underlying reasons for this failure and in coming to a logical decision for changing the concept.
在过去几年中，布比卡因和/或阿片类药物的硬膜外镇痛已成为术后疼痛治疗中的一项重要技术。仅使用布比卡因时，2%至20%的患者治疗效果不佳。为了确定并评估其潜在原因，我们对51例常规患者以及212例患者中镇痛效果不佳的6例患者进行了前瞻性硬膜造影检查。所有患者主要接受布比卡因治疗。将观察到并记录的影像学数据与个体镇痛结果进行比较。方法：所有检查均在置管后24小时内进行。在影像学引导下于两个不同位置注射造影剂，并在前后位射线路径中记录分布末端情况。第一组（n = 26）记录了导管位置以及3.0 ml碘帕醇造影剂的分布情况。第二组（n = 25）以同样方式记录导管位置，但对逐步注射的造影剂（3.0 ml + 2.0 ml + 3.0 ml）的分布情况进行记录。基于这些发现，我们在接下来的患者（第三组，n = 212）中改变了硬膜外导管置入理念，仅对治疗失败的患者（第三组a，n = 6）进行影像学检查。现在我们术前而非术后大多在侧卧位经腰部置管，改为在坐位时将导管尽可能靠近待治疗节段的中心位置。结果：仅27例患者显示导管位置理想且造影剂分布典型。其中3例患者仍未成功治疗。12例患者造影剂扩散不均匀，5例患者造影剂仅见于硬膜外腔一侧。这17例患者中有一半（n = 9）需要辅助治疗。令人惊讶的是，8例硬膜外旁导管位置的患者中有4例治疗成功。讨论：通过硬膜外导管注射进行有效的布比卡因治疗并不能确凿证明硬膜外导管位置正确。如果导管位于硬膜外腔，布比卡因治疗的实际效果主要取决于药物的分布。然而，导管在硬膜外腔的位置——中央或外侧——似乎并非特别重要。若要仅用布比卡因或与阿片类药物联合实现高质量镇痛，导管通常应放置在靠近或更好地置于待治疗节段的中心位置。结果表明，在硬膜外导管治疗失败的情况下，硬膜造影检查对于确定并评估失败的潜在原因以及做出合理的理念改变决策非常有帮助。
