Blanco D, Llamazares J, Rincón R, Ortiz M, Vidal F
Servei d'Anestesiologia, Reanimació i Teràpia del Dolor Hospital Universitari Germans Trías i Pujol, Barcelona, Spain.
Anesthesiology. 1996 Jun;84(6):1312-6. doi: 10.1097/00000542-199606000-00006.
In upper abdominal or chest surgery, the segmental approach to thoracic epidural space has the advantage of reducing the total dose of local anesthetic needed. This approach, however, is associated with greater risk of neurologic damage or dural puncture. The aim of this study was to assess the success and the degree of difficulty in advancing a 19-G catheter from the lumbar epidural space to the thoracic level in patients aged 0-96 months.
In 39 patients undergoing abdominal surgery, the cutaneous distance between the L4-L5 and T10-T11 interspaces was measured, and an appropriate length of 19-G catheter was inserted into the epidural space through an 18-G Tuohy needle with bevel directed cephalad. The intent was to advance the full length of catheter measured to reach the objective. The tips were observed radiologically, and all those positioned cephalad to the T12 level were considered well placed. The degree of difficulty in advancing the catheter was classified as easy, difficult, or impossible. Complications reported were vascular and/or spinal puncture and difficulty removing the catheter.
The catheter tip reached T10-T12 in 7 patients, L2 in 1, L3 in 8, and L4-L5 in 23. Forty-eight percent of the catheters described as easily advanced remained at the L4-L5 level, and only 22% reached the desired level. Difficult insertions occurred in eight patients, in whom the objective was never reached. One case of intravascular insertion was reported. All catheters were removed without difficulty.
The 19-G catheter is inappropriate for use in reaching the thoracic epidural space by the lumbar approach. Easy entrance of a catheter is not a reliable sign of having reached the desired level.
在上腹部或胸部手术中，采用节段性穿刺进入胸段硬膜外间隙的方法具有减少局部麻醉药总用量的优势。然而，这种方法与更高的神经损伤或硬膜穿刺风险相关。本研究的目的是评估在0至96个月龄的患者中，将19G导管从腰段硬膜外间隙推进至胸段水平的成功率及难度。
对39例接受腹部手术的患者，测量L4-L5和T10-T11椎间隙之间的皮肤距离，并通过18G头端斜面向上的Tuohy针将合适长度的19G导管插入硬膜外间隙。目的是将测量好的导管全长推进至目标位置。通过影像学观察导管尖端位置，所有位于T12水平以上的导管均视为放置良好。将导管推进的难度分为容易、困难或无法推进。记录的并发症包括血管穿刺和/或脊髓穿刺以及拔管困难。
7例患者的导管尖端到达T10-T12，1例到达L2，8例到达L3，23例到达L4-L5。在描述为容易推进的导管中，48%停留在L4-L5水平，只有22%到达预期水平。8例患者插管困难，未达到目标位置。报告1例血管内插管。所有导管均顺利拔除。
19G导管不适合通过腰椎途径进入胸段硬膜外间隙。导管容易置入并非到达预期水平的可靠标志。
