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PNEUMOCEPHALUS AFTER COMBINED SPINAL-EPIDURAL ANALGESIA FOR LABOUR USING LOSS OF RESISTANCE TO SALINE TECHNIQUE
ESRA Academy. Jones J. Sep 8, 2016; 138364; 0202 Topic: REGIONAL ANAESTHESIA (RA) TECHNIQUES - CLINICAL IMPLICATIONS
Dr. Joana Jones
Dr. Joana Jones

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Abstract
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Background and Aims:

A literature search revealed no previous report of Pneumocephalus (PC) following epidural anaesthesia using the 'loss of resistance to saline' (LORS) technique for identification of the epidural space. We report a case of PC after combined spinal-epidural (CSE) analgesia for labor using LORS and present a possible explanation based on cerebrospinal fluid (CSF) dynamic principles.


Methods:

Various attempts to perform a CSE analgesia at L3-L4 interspace, in the lateral position using LORS were unsuccessful. After sitting the patient, using the same technique, epidural space was successfully located and dura was punctured with a 27G needle. Local anaesthetic was injected intrathecally and a catheter was left in the epidural space. The patient immediately reported a severe holocranial headache. Unremitting headache without postural features continued the next days and was treated conservatively.  On postpartum day 2, the patient presented a tonic-clonic seizure. Brain CT showed intraventricular PC (arrows). Oxygen was added to therapy with clinical improvement.

Results:

Sudden change to the sitting position and abdominal strength increased lumbar CSF pressure with abrupt efflux of fluid through the dural hole. Rapid CSF loss and patient’s intermittent deep breaths concurred to a decrease of CSF compartment pressure (bellow atmospheric) with brisk entrance of air through the Tuohy needle before catheter insertion.

Conclusions:

PC is an unusual cause of headache and seizures in the postpartum period after neuraxial blocks. Use of LORS does not exclude this complication if a dural puncture occurs. Immediate onset of headache and absence of postural features should alert the anaesthesiologist to this entity.

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