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INTRODUCTION: Unintentional dural puncture (UDP) occurs in 0.5-1.5% of labour epidural analgesia cases. To date, little is known about evidence of UDP-related complications. This work aimed to assess the incidence of intrapartum and postpartum complications in parturients who experienced UDP. METHODS: This is a 10-year retrospective observational study on parturients admitted to our centre who presented UDP. Data collection gathered UDP-related complications during labour and postpartum. All women who displayed UDP received medical therapy and bed rest. An epidural blood patch (EBP) was not used in this population. Once asymptomatic, patients were discharged from the hospital. RESULTS: Out of 7718 neuraxial analgesia cases, 97 cases of UDP occurred (1.25%). During labour, complications appeared in a small percentage of analgesia procedures performed, including total spinal anaesthesia (1.0%), extended motor block (3%), hypotension (4.1%), abnormal foetal heart rate (2%), inadequate analgesia (14.4%), and general anaesthesia following neuraxial anaesthesia failure (33.3% of emergency caesarean sections). During the postpartum period, 53.6% of parturients exhibited a postdural puncture headache, 13.4% showed neurological symptoms, and 14.4% required neurological consultation and neuroimaging. No patient developed subdural hematoma or cerebral venous sinus thrombosis; one woman presented posterior reversible encephalopathy syndrome associated with eclampsia. Overall, 82.5% of women experienced an extension of hospital stay. CONCLUSION: Major complications occurred in a small percentage of patients during labour. However, since they represent high-risk maternal and neonatal health events, a dedicated anaesthesiologist and a trained obstetric team are essential. No major neurological complications were registered postpartum, and EBP was not performed. Nevertheless, all patients with UDP were carefully monitored and treated until complete recovery before discharge, leading to an extension of their hospitalization.
RESUMO
Pulmonary complications have a significant impact on morbidity and mortality in patients after major surgery. Lung ultrasound can be used at the bed-side, and has gained widespread acceptance in the intensive care unit. We conducted a prospective study to evaluate whether lung ultrasound could be used as a predictive marker for postoperative ventilatory support in high-risk surgical patients. We included 109 patients admitted to the intensive care unit while having mechanical ventilation of the lungs following major surgery. The PaO2 /FI O2 ratio was calculated on admission and an ultrasound examination performed, including: lung ('lung ultrasound score', number of consolidated lung areas); cardiac (mitral flow); and inferior vena cava imaging (diameter and respiratory variation). Respiratory outcomes included: the need for ventilation support (mechanical ventilation, non-invasive ventilation or high-flow nasal cannula oxygen therapy); acute respiratory distress syndrome; cardiogenic pulmonary oedema; and early or late pulmonary infection. Patients with a lung ultrasound score ≥ 10 had a lower PaO2 /FI O2 ratio, and needed more postoperative ventilatory support, than patients with lung ultrasound score < 10. Twenty patients had acute respiratory distress syndrome, and 14 had cardiogenic pulmonary oedema. The presence of ≥ 2 areas of consolidated lung was associated with a lower PaO2 /FI O2 ratio, postoperative ventilatory support, longer intensive care stay and episodes of ventilator-associated pneumonia requiring antibiotics. Our results suggest that at intensive care unit admission, lung ultrasound scoring and detection of atelectasis can predict postoperative pulmonary outcomes after major visceral surgery, and could enhance bed-side decision making.
