Epidurales H matom nach Single shot-Epiduralan sthesie

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Abstract
Die Entstehung eines epi- oder subduralen Hämatoms ist eine bekannte, jedoch sehr seltene Komplikation rückenmarknaher Leitungsanästhesien [9]. Wesentliche Ursachen sind unter anderem eine gestörte Blutgerinnung und das Punktionstrauma, wobei letzteres den auslösenden Faktor darstellt und das Ausmaß der Gefäßläsion bestimmt, während erstere die eingetretene Blutung unterhalten kann. In dem hier geschilderten Fall einer Epiduralanästhesie bei einer gesunden 30jährigen Patientin ist infolge mehrfacher Punktionsversuche das Gewebstrauma als Hämatomursache anzusehen, zumal keine präoperative Heparinisierung durchgeführt wurde. Wichtig für die Prognose ist das rechtzeitige Erkennen von Frühsymptomen, die in unserem Fall erst nach vier Tagen (!) auftraten sowie der umgehende Einsatz spezieller Diagnostik und – falls nötig – der operativen Hämatomausräumung. Ob hinsichtlich der Hämatomrate der Single shot- gegenüber der Katheter-Technik der Vorrang zu geben wäre, wird sich derzeit wohl kaum statistisch ermitteln lassen. The formation of an epidural or subdural haematoma is a well-known but very rare complication when anaesthetic procedures are conducted near the spinal cord. The major reasons are impaired blood coagulation and the trauma of puncture, which represents the initiating factor and determines the extent of the vascular lesion, while defective coagulation may cause the bleeding to continue. We report on a 30-year-old slender female patient of ASA group II undergoing epidural anaesthesia at L3/4 with a 19-gauge Crawford needle for an ankle joint injury. Unexpected puncture difficulties made several approaches necessary. Prevention of thrombosis with low-molecular heparin was not started preoperatively but 8 h following the intervention. On the first postoperative day the patient was mobilized and, in spite of the repeated punctures, there were no complaints until the fourth postoperative day. Subsequently, sudden significant complaints occurred, first suggesting infection near the spinal cord. Immediate magnetic resonance imaging revealed an epidural haematoma, which did not require intervention. Puncture of the spinal fluid was not performed. Laboratory analysis of coagulation showed a prothrombin time of 56%; PTT was normal with 36 s. Following three days of symptomatic therapy, the complaints had improved markedly, so that mobilization could be started again. For another 10 days the patient had a minor diffuse sensation of pressure when moving the lumbar spine in this region. Subsequently, there were no complaints at all, as proved by an investigation one year later. Unfortunately, the patient refused to undergo another MRT at that time. In the present case the haematoma was caused by tissue trauma due to several puncture attempts. The prognosis largely depends on early recognition of the symptoms, which in our case became manifest only after several days, as well as the immediate employment of special diagnostic procedures and, if necessary, surgical intervention. At present, it is not possible to conduct a statistical analysis on the question of whether there is a higher incidence of haematoma in single-shot anaesthesia than in continuous anaesthesia.

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