Michel H, Steffen P, Weichel T, Seeling W
Universitätsklinik für Anästhesiologie, Klinikum der Universität Ulm.
Anaesthesiol Reanim. 1997;22(3):69-79.
Patients suffering from vascular disease are often a challenge for the acute pain service. Ischaemia, impaired wound healing, stump and phantom limb pain often require a complex analgesic regimen. Invasive measures such as spinal or epidural catheters can be very helpful but carry the risk of infection, as shown by this case report. A 53-year-old woman with a ten-year history of diabetes developed arterial vascular disease. Her right lower leg had been amputated two years previously. She was now admitted with necroses of the left forefoot. A bypass operation was performed under general anaesthesia. Because of intractable ischaemic pain, she was provided with an epidural catheter by the acute pain service. The bypass occluded, however, and a few days later her left lower leg also had to be amputated, this operation being performed under epidural anaesthesia with bupivacaine. The catheter was subsequently used for postoperative pain control and as a means to prevent phantom limb pain. When signs of superficial catheter infection were noticed days later, the catheter was immediately removed. Intractable pain then developed in the left leg which could not be sufficiently controlled with opioids and NSAIDs, and so a second epidural catheter was inserted one segment rostrally. Several days later the infected vascular prosthesis had to be removed followed by amputation of the thigh, this operation also being performed in epidural anaesthesia. Eleven days after insertion of the first epidural catheter, the patient complained of low back pain and headache. Examination by a neurologist revealed no signs of intraspinal infection. The second epidural catheter dislocated at this point in time and it was decided to introduce a third one, this being the only means to treat the otherwise intractable stump pain. Ten days later meningism, Kernig's sign and leucocytosis developed. NMR tomography detected intraspinal fluid in the epidural space at the dorsal border of the spinal canal. A hemilaminectomy was performed. The spinal epidural space showed signs of inflammation of the adipose tissue, but no pus. A little necrotic material and residues of an old haematoma were removed and the epidural space was lavaged. Specimens taken from the epidural material revealed colonisation with staphylococcus epidermidis, which was sensitive to the broad spectrum antibiotics formerly given to the patient to treat the infection in the left stump. By the next day, all signs of epiduritis had disappeared and the patient recovered completely.
血管疾病患者常常给急性疼痛治疗服务带来挑战。缺血、伤口愈合受损、残端痛和幻肢痛往往需要复杂的镇痛方案。诸如脊髓或硬膜外导管等侵入性措施可能非常有用，但存在感染风险，本病例报告即表明了这一点。一名患有十年糖尿病史的53岁女性患上了动脉血管疾病。她的右小腿两年前已被截肢。她现因左前足坏死入院。在全身麻醉下进行了搭桥手术。由于存在难以忍受的缺血性疼痛，急性疼痛治疗服务团队为她置入了一根硬膜外导管。然而，搭桥血管闭塞，几天后她的左小腿也不得不被截肢，此次手术在布比卡因硬膜外麻醉下进行。随后该导管用于术后疼痛控制以及预防幻肢痛。几天后发现有浅表导管感染迹象时，导管被立即拔除。随后左腿出现难以忍受的疼痛，使用阿片类药物和非甾体抗炎药无法充分控制，于是在更高一个节段置入了第二根硬膜外导管。几天后，感染的血管假体不得不被移除，随后进行了大腿截肢手术，此次手术同样在硬膜外麻醉下进行。在第一根硬膜外导管置入11天后，患者抱怨出现腰痛和头痛。神经科医生检查未发现脊髓内感染迹象。此时第二根硬膜外导管移位，于是决定置入第三根，这是治疗原本难以忍受的残端痛的唯一方法。十天后出现了脑膜刺激征、克尼格征和白细胞增多。核磁共振断层扫描在椎管背侧边界的硬膜外间隙检测到脊髓液。进行了半椎板切除术。脊髓硬膜外间隙显示脂肪组织有炎症迹象，但无脓液。清除了少量坏死物质和陈旧血肿的残留物，并对硬膜外间隙进行了冲洗。从硬膜外物质中采集的样本显示有表皮葡萄球菌定植，该菌对之前用于治疗患者左残端感染的广谱抗生素敏感。到第二天，所有硬膜外炎症迹象均消失，患者完全康复。
