Aspectos técnicos de los bloqueos epidurales

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Aspectos técnicos de los bloqueos epidurales

  1. 1. ASPECTOS TÉCNICOS DE LOS BLOQUEOS EPIDURALES Dra. Marta Perepérez Sº de Anestesia y Reanimación CLÍNICA UBARMIN
  2. 2. ESPACIO EPIDURAL “Injected material displaces the dura forward and inward, producing a stretch of the nerve roots that leads to lysis of neural adhesions.”Rabinovitch DL, Peliowski A, Furlan AD. Influence of lumbar epidural injection volume on pain relief for radicular leg pain and/or low back pain. Spine J. 2009 Jun; 9 (6): 509-17.
  3. 3. FÁRMACOS FALTA DE CONSENSOA FAVOR MAYORITARIAMENTE DE MEZCLA DE: CCO + AL
  4. 4. FÁRMACOS DOLOR → LA REACCIÓN INFLAMATORIA ↓ ALIVIO → INTERRUPCIÓN SÍNTESIS DE CITOQUINAS Burnett C. Recent advancements in the treatment of lumbar radicular pain. Curr Opin Anaesthesiol, 2008, Aug; 21 (4):452-6. ↓ CCO → DISMINUYEN:• El edema• La vasodilatación capilar• La proliferación de fibroblastos• La cicatrización• La síntesis de PLA2
  5. 5. FÁRMACOS ¿QUÉ CCO? Depo-MedrolND VE TrigonManchikant L. Role of Neuraxial Steroids in Interventional Pain Management. Pain Physician, 2002; 2:182-199.
  6. 6. FÁRMACOS ¿QUÉ PERIODICIDAD?Manchikant L. Role of Neuraxial Steroids in Interventional Pain Management. Pain Physician, 2002; 2:182-199.
  7. 7. FÁRMACOS ¿QUÉ PERIODICIDAD?Marinangeli F, Ciccozzi A, Donatelli F, Paladini A, Varrassi G. Clinical use of spinal or epidural steroids. Minerva Anestesiol. 2002 Jul-Aug;68(7-8):613-20. Steroidal toxicity seems to be related to the polyethylenic glycole vehicle. Anyway, slow release formulations contain less concentrated polyethylenic glycole. The epidural administration, a correct dilution of steroid with local anesthetics solution and/or saline solution, and a limited number of injections (no more than three) allows a significant reduction of steroid neurotoxicity.
  8. 8. FÁRMACOS CCO DE ACCIÓN PROLONGADANoe CE, Haynsworth RF Jr. Comparison of epidural Depo_medrol vs. Aqueous betamethasone in patients with low back pain. Pain Pract. 2003 Sep; 3 (3):222-5 ↓ ACETATO DE METILPREDNISOLONA (40-80 mg) Y ACETÓNIDO DE TRIAMCINOLONA (80 mg) Robinson D et al.The effects of different doses of lumbosacral epidural steroids for patients with lumbosacral radiculopathy and spinal stenosis. Ameriacan Academy of Pain Medicine. 22nd Annual Meeting. February 22-25, 2006.Owlia M B, Salimzadeh A, Alishiri Gh, Haghighi A. Comparison of two doses of corticosteroid in epidural steroid injection for lumbar radicular pain. Singapore Med J 2007; 48 (3) : 24-45.
  9. 9. FÁRMACOS AL ↓ PROS Y CONTRAS DE LOS AL:• Capacidad de romper el círculo vicioso: Dolor muscular, espasmo, isquemia, dolor• Beneficio psicológico• Comprobación de la inyección epidural• CONTRAS: HipoTA, bloqueo sensitivo y motor prolongado ↓ VOLUMEN ↓ DEPENDE DE LA VÍA DE ABORDAJE
  10. 10. VÍAS DE ABORDAJECAUDAL INTERLAMINAR TRANSFORAMINAL30-40mL 8-12mL 2-4 mL
  11. 11. VÍAS DE ABORDAJE EFICACIA SUPERIOR DE LAS VÍAS INTERLAMINAR Y TRANSFORAMINAL VS LA CAUDAL EFICACIA SUPERIOR DE LA VÍA TRANSFORAMINAL EN HERNIAS TRANSFORAMINALES Y EN ESTENOSIS DE CANALLee JH, Moon J, Lee SH. Comparison of effectiveness according to different approaches of epidural steroid injection inlumbosacral herniated disk and spinal stenosis. J Back Musculoskelet Rehabil. 2009;22(2):83-9.
  12. 12. VÍAS DE ABORDAJE Abordaje intraforaminalPARAPLEJIA (Houten JK, Erico TJ. Paraplegia after lumbosacral nerve root block: report of three cases. Spine J 2002; 2:70-75.) ( Glaser SE and Falco F. Paraplegia following thoracoumbar transforaminal epidural steroid injection, pain Physician 2005; 8:309-314.) (Epidural Steroids in the Management of Chronic Spinal Pain: A Systematic review. Pain Physician 2007, 10:185-212.)MAYOR DIFICULTAD TÉCNICA
  13. 13. COMPLICACIONES 3 TIPOS•DERIVADAS DEL USO DE AL•DERIVADAS DE LA TÉCNICA•DERIVADAS DEL USO DE CCO
  14. 14. COMPLICACIONES: por la técnica 293.050 epidurales de las cuales 27.975 eran para control de dolor crónicoT. M. Cook, D. Counsell and J. A. W. Wildsmith. Major complications of central neuraxial block: report on the Third NationalAudit Project of the Royal College of Anaesthetists. British Journal of Anaesthesia 102 (2): 179–90 (2009).
  15. 15. COMPLICACIONES: por el uso de CCO
  16. 16. COMPLICACIONES: otras• CPPD• REACCIONES VASOVAGALES• DOLOR LOCAL O EXACERBACIÓN DE LA RADICULOPATÍA DURANTE LAPUNCIÓN• ARACNOIDITIS Y NEUROTOXICIDAD• LIPOMATOSIS EPIDURAL• MENORRAGIA O AMENORREA
  17. 17. CONCLUSIONES• La inyección epidural conjunta de CCO y de AL se ha demostrado eficaz.• Las 3 vías de administración son válidas.• El tipo de CCO y la periodicidad de los BED deben individualizarse en cada centro: protocolización (Cohen SP, Hayek SM, Datta S, Bajwa ZH, Larkin TM, Griffith S, Hobelmann G, Christo PJ, White R. Incidence and root cause analysis of wrong-site pain management procedures: a multicenter study. Anesthesiology. 2010 Mar;112(3):711-8.• Es fundamental la adopción de medidas de seguridad para el paciente: s/t estudio preoperatorio, monitorización, ingreso 7-10 horas y seguimiento efectos secundarios.
  18. 18. GRACIAS
  19. 19. Kennedy DJ, Dreyfuss P, Aprill CN, Bogduk N. Paraplegia following image-guided transforaminal lumbar spineepidural steroid injection: two case reports. Pain Med. 2009 Nov;10(8):1389-94.OBJECTIVE: To present two case reports of a rare but devastating injury after image-guided,lumbar transforaminal injection of steroids, and to explore features in common with previouslyreported cases. BACKGROUND: Image (fluoroscopic and computed tomography [CT])-guided,lumbar transforaminal injections of corticosteroids have been adopted as a treatment for radicularpain. Complications associated with these procedures are rare, but can be severe. CASEREPORTS: An 83-year-old woman underwent a fluoroscopically guided, left L3-L4, transforaminalinjection of betamethasone (Celestone Soluspan). A 79-year-old man underwent a CT-guided,right L3-L4, transforaminal injection of methylprednisolone (DepoMedrol). Both patientsdeveloped bilateral lower extremity paralysis, with neurogenic bowel and bladder, immediatelyafter the procedures. Magnetic resonance imaging scans were consistent with spinal cordinfarction. There was no evidence of intraspinal mass or hematoma.CONCLUSION: These cases consolidate a pattern emerging in the literature. Distal cord andconus injury can occur following transforaminal injections at lumbar levels, whether injection is onthe left or right. This conforms with the probability of radicular-medullary arteries forming anarteria radicularis magna at lumbar levels. All cases used particulate corticosteroids, whichpromotes embolization in a radicular artery as the likely mechanism of injury. The risk of thiscomplication can be reduced, and potentially eliminated, by the utilization of particulate freesteroids, testing for intra-arterial injection with digital subtraction angiography, and a preliminaryinjection of local anesthetic.

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