Bloqueo y Anestesia Epidural II
Bloqueo y Anestesia Epidural II
Bloqueo y Anestesia Epidural II
Hay cuatro vas bien conocidas del dolor torcico (6) (Figura l).
En la prctica de la analgesia torcica, las nicas vas aferentes de conduccin en
la cuales se puede intentar utilizar tcnicas para alivar el dolor son las vas
incluidas en los nervios intercostales. Estas vas pueden ser interrumpidas
perifricamente por bloqueo de los nervios intercostales, ms proximalmente por
bloqueo paraverteveral y en su origen o ms arriba en el neuroeje por bloqueo
extradural o intratecal. Por lo general, cuanto ms central es el bloqueo, ms
amplia y efectiva es la analgesia, mayor el nmero de efectos secundarios y
potencialmente ms dainas las complicaciones. Las indicaciones incluyen la
pancreatitis, el herpes zoster agudo y neuralgia postherptica, el sndrome de
dolor postorocotoma y las fracturas de costilla. En este ltimo caso, la colocacin
de frulas y las dificultades para toser pueden producir atelectasia, hipoxemia y
neumona intercurrente. El control efectivo del dolor es un aspecto crtico del
tratamiento de los pacientes que tienen fracturas costales mltiples e inestabilidad
de la pared torcica, y puede evitar la necesidad de intubacin (11). Para tratar a
estos pacientes, se han utilizado con xito la bupivacana (70), 2 rng de morfina
por va epidural torcica alta (71), infusiones de morfina-bupivacana (72), fentanilo
en infusin continua por va epidural (73) y morfina epidural frente a morfina iv
(74). La adicin de antiinflamatorios no esteroideos a infusiones de
morfina/bupivacana a bajas dosis no parece mejorar la analgesia en los pacientes
con dolor postoracotoma (75). En relacin con la depresin respiratoria, hay va-
rios factores de riesgo que pueden aumentar su incidencia como son: la
administracin de frmacos hidroflicos, dosis altas o repetidas de opiceos por va
epidural, la administracin torcica, el uso concomitante de opiceos por va
parenteral, la edad o caquexia del paciente y la neumopata coexistente (60).
Para realizarlo el paciente se coloca sentado con la cabeza apoyada sobre una
mesita con una almohada; debe flexionar la cabeza intentando contactar mentn y
esternn. El anestesilogo trabajar por detrs y de pie. El abordaje aconsejado
es medial. La apfisis espinosa ms prominente es C7.
Otra opcin es colocar al paciente en decbito lateral con una almohada corta bajo
la cabeza y flexionar sta, intentando mantener la horizontalidad de todo el eje de
la columna vertebral. Con ello intentamos evitar las reacciones vagales o si se
producen, el poder seguir con el procedimiento sin que se tengan que retirar
apresuradamente aguja y catter, como ocurrira en posicin sentada. A veces
esta posicin es necesaria por las caractersticas del paciente.
1. Ciruga perineal.
2. Herniorrafia inguinal y femoral.
3. Cistoscopia y ciruga uretral.
4. Clnica del dolor: sndrome de dolor lumbar (en que interesa llegar o alcanzar
el nivel L5-S1 pero existe imposibilidad de abordaje a ese nivel por ciruga previa
en la zona) y coccigodinia. El abordaje caudal permite subir un catter por el
espacio epidural hasta ese nivel e inyectar el anestsico local o corticoide.
El bloqueo caudal se utilizaba ampliamente para la analgesia durante el parto,
pero ha sido prcticamente sustituido por el bloqueo epidural lumbar.
Esta tcnica es ms fcil de realizar en los nios que en los adultos. En pediatra
existe el riesgo de inyeccin intrasea con suma facilidad al ser la cortical sea
menos resistente a la punta de la aguja y simular la resistencia del ligamento
sacrococcgeo (80)
Figura 25. posicin del paciente para bloqueo caudal. Ntese la colocacin del
arco de fluoroscopia.
Existen diversos modelos de agujas para el bloqueo caudal, pero basta con una
simple aguja hipodrmica desechable de 4 cm y calibre 21 o 23. Si se utiliza un
catter, la aguja debe tener un calibre suficientemente amplio (17-18 G) para que
el catter pueda pasar a travs de su luz.
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1.- La anestesia epidural torcica:
a.- aumenta el MVO2 miocrdico
b.- disminuye el MVO2 miocrdico (OK)
c.- no afecta al MVO2 miocrdico
d.- Aumenta los cambios en el ST del ECG