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Entwicklung eines Weichteilulkus nach periduraler Langzeitinfusion

Development of a soft tissue ulcer after long-term peridural infusion

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Zusammenfassung

Lokalanästhetika (LA), in klinischen Konzentrationen verabreicht, beinhalten ein gewebstoxisches Potenzial, dessen Auswirkungen in der Praxis jedoch selten beobachtet werden. Es wird über den Fall einer 74-jährigen Patientin (Body-Mass-Index 16,8 kg/m2) mit einem metastasierenden Bronchuskarzinom berichtet. Sie hatte wegen therapierefraktärer Schmerzen einen getunnelten thorakalen Periduralkatheter (PDK) erhalten. Unter einer kontinuierlichen periduralen Infusion von 0,49%igem Bupivacain, 0,0036%igem Morphium und 0,0001%igem Clonidin (3 ml/h) entwickelte sich nach 8 Wochen thorakal-paravertebral ein derbes Weichteilulkus mit kristallinem Fremdmaterial (KFM) im Ulkusgrund. Die thorakale Computertomographie (CT) bestätigte eine Dislokation des PDK in die Subkutis mit einer ausgedehnten Flüssigkeitsansammlung bis zum M. erector spinae. Die histologische Untersuchung zeigte eine areaktive Nekrose mit Einschlüssen von KFM; die chemische Analyse des KFM erbrachte den Nachweis von Bupivacain, Morphium und Natriumchlorid. Das Weichteilulkus war wahrscheinlich durch Ausfällungen des LA-Gemisches entstanden.

Abstract

Local anaesthetic agents (LA) in clinical concentrations have the potential for tissue toxicity, although this is rarely observed in clinical practice. The case of a 74-year-old female patient (BMI 16.8 kg/m2) with a metastasising bronchial carcinoma is reported, who suffered from severe back pain due to tumour infiltration. For pain management a tunnelled continuous thoracic peridural catheter (PC) was placed and a mixture of bupivacaine 0.49%, morphine 0.0036% and clonidine 0.0001% was infused at 3 ml/h. After 8 weeks of continuous infusion an ulcer developed in the soft tissue close to the thoracic spine containing whitish crystalline material (CM). A computed tomography examination revealed a subcutaneously displaced PC with extensive fluid collection reaching down to the sacrospinalis muscle. Histologically an unreactive necrosis with enclosed CM of unknown etiology was found. The result of the chemical analysis of the deposits demonstrated bupivacaine, morphine and sodium chloride. It is concluded that the soft tissue ulcer was probably caused by precipitation of the LA mixture.

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Literatur

  1. Benoit PW, Belt WD (1970) Destruction and regeneration of skeletal muscle after treatment with a local anaesthetic, bupivacaine (marcaine). J Anat 107: 547–556

    PubMed  CAS  Google Scholar 

  2. Benoit PW (1978) Microscarring in skeletal muscle after repeated exposures to lidocaine with epinephrine. J Oral Surg 36: 530–533

    PubMed  CAS  Google Scholar 

  3. Carlson BM, Emerick S, Komorowski TE et al. (1992) Extraocular muscle regeneration in primates. Local anesthetic-induced lesions. Ophthalmology 99: 582–589

    PubMed  CAS  Google Scholar 

  4. Carlson BM, Rainin EA (1985) Rat extraocular muscle regeneration. Repair of local anesthetic-induced damage. Arch Ophthalmol 103: 1373–1377

    PubMed  CAS  Google Scholar 

  5. Carlson BM, Shepard B, Komorowski TE (1990) A histological study of local anesthetic-induced muscle degeneration and regeneration in the monkey. Orthop Res 8: 485–494

    Article  CAS  Google Scholar 

  6. Classen AM, Wimbish GH, Kupiec TC (2004) Stability of admixture containing morphine sulphate, bupivacaine hydrochloride, and clonidine hydrochloride in an implantable infusion system. J Pain Symptom Manage 28(6): 603–611

    Article  PubMed  CAS  Google Scholar 

  7. Foster AH, Carlson BM (1980) Myotoxicity of local anesthetics and regeneration of the damaged muscle fibers. Anesth Analg 59: 727–736

    Article  PubMed  CAS  Google Scholar 

  8. Gerheuser F, Roth A (2007) Periduralanästhesie. Anaesthesist 56: 499–526

    Article  PubMed  CAS  Google Scholar 

  9. Hall-Craggs EC (1980) Early ultrastructural changes in skeletal muscle exposed to the local anaesthetic bupivacaine (Marcaine). Br J Exp Pathol 61: 139–149

    PubMed  CAS  Google Scholar 

  10. Hogan Q, Dotson R, Erickson S et al. (1994) Local anesthetic myotoxicity: a case and review. Anesthesiology 80: 942–947, Rev 71: 849–908

    Google Scholar 

  11. Irwin W, Fontaine E, Agnolucci L et al. (2002) Bupivacaine myotoxicity is mediated by mitochondria. J Biol Chem 277: 12221–12227

    Article  PubMed  CAS  Google Scholar 

  12. Komai H, Lokuta AJ (1999) Interaction of bupivacaine and tetracaine with the sarcoplasmic reticulum Ca2+ release channel of skeletal and cardiac muscles. Anesthesiology 90: 835–843

    Article  PubMed  CAS  Google Scholar 

  13. Komorowski TE, Shepard B, Okland S et al. (1990) An electron microscopic study of local anesthetic-induced skeletal muscle fiber degeneration and regeneration in the monkey. J Orthop Res 8: 495–503

    Article  PubMed  CAS  Google Scholar 

  14. Kyttä J, Heinonen E, Rosenberg PH et al. (1986) Effects of repeated bupivacaine administration on sciatic nerve and surrounding muscle tissue in rats. Acta Anaesthesiol Scand 30: 625–629

    Article  PubMed  Google Scholar 

  15. Lerch N, Gerber H, Oehen HP, Schorno HX (1998) Bupivacaine free base deposits in peridural space after prolonged application for chronic cancer pain. Abstract Nr. 66, Proceedings XVII. Annual ESRA Congress, Geneva

  16. Nonaka I, Takagi A, Ishiura S et al. (1983) Pathophysiology of muscle fiber necrosis induced by bupivacaine hydrochloride (marcaine). Acta Neuropathol 60: 167–174

    Article  PubMed  CAS  Google Scholar 

  17. Nouette-Gaulain K, Sirvent P, Canal-Raffin M et al. (2007) Effects of intermittent femoral nerve injections of bupivacaine, levobupivacaine, and ropivacaine on mitochondrial energy metabolism and intracellular calcium homeostasis in rat psoas muscle. Anesthesiology 106(5): 1026–1034

    Article  PubMed  CAS  Google Scholar 

  18. Parris WC, Dettbarn WD (1988) Muscle atrophy following nerve block therapy. Anesthesiology 69: 289

    Article  PubMed  CAS  Google Scholar 

  19. Schipper I, Lüthi M (1994) A case of diplopia after retrobulbar anesthesia for cataract operation. Klin Monatsbl Augenheilkd 204: 176–180

    Article  PubMed  CAS  Google Scholar 

  20. Schultz E, Lipton BH (1978) The effect of marcaine on muscle and non-muscle cells in vitro. Anat Rec 191: 351–369

    Article  PubMed  CAS  Google Scholar 

  21. Taylor G, Devys JM, Heran F, Plaud B (2004) Early exploration of diplopia with magnetic resonance imaging after peribulbar anaesthesia. Br J Anaesth 92: 899–901

    Article  PubMed  CAS  Google Scholar 

  22. Wakata N, Sugimoto H, Iguchi H (2001) Bupivacaine hydrochloride induces muscle fiber necrosis and hydroxyl radical formation – dimethyl sulphoxide reduces hydroxyl radical formation. Neurochem Res 26: 841–844

    Article  PubMed  CAS  Google Scholar 

  23. Weissauer W., Biermann E, Justitiare des Berufsverbandes Deutscher Anästhesisten, Nürnberg (1998) Therapiefreiheit und Arzneimittelzulassung, Stellungnahme zur Erwiderung von J Jage. Anaesthesist 47: 605–609

    Article  Google Scholar 

  24. Wulf H, Gleim M, Mignat C (1994) The stability of mixtures of morphine hydrochloride, bupivacaine hydrochloride, and clonidine hydrochloride in portable pump reservoirs for the management of chronic pain syndromes. J Pain Symptom Manage 9(5): 308–311

    Article  PubMed  CAS  Google Scholar 

  25. Yagiela JA, Benoit PW, Buoncristiani RD et al. (1981) Comparison of myotoxic effects of lidocaine with perinephrine in rats and humans. Anesth Analg 60: 471–480

    Article  PubMed  CAS  Google Scholar 

  26. Zink W, Bohl JRE, Hacke N et al. (2005) The long-term myotoxic effects of bupivacaine and ropivacaine after continuous peripheral nerve blockades. Anesth Analg 101: 548–554

    Article  PubMed  CAS  Google Scholar 

  27. Zink W, Graf BM (2003) Toxikologie der Lokalanästhetika. Anaesthesist 52: 1102–1123

    Article  PubMed  CAS  Google Scholar 

  28. Zink W, Graf BM (2004) Local anesthetic myotoxicity. Reg Anesth Pain Med 29: 333–340

    PubMed  CAS  Google Scholar 

  29. Zink W, Graf BM, Sinner B et al. (2002) Differential effects of bupivacaine on intracellular Ca2+ regulation: potential mechanisms of its myotoxicity. Anesthesiology 97: 710–716

    Article  PubMed  CAS  Google Scholar 

  30. Zink W, Kunst G, Martin E et al. (2002) Differential effects of S(-)-ropivacaine and bupivacaine on intracellular Ca2+ homeostasis in mammalian skeletal muscle fibers. Anesthesiology 96: A972

    Google Scholar 

  31. Zink W, Missler G, Sinner B et al. (2005) Differential effects of bupivacaine and ropivacaine enantiomers on intracellular Ca2+ regulation in murine skeletal muscle fibers. Anesthesiology 102: 793–798

    Article  PubMed  CAS  Google Scholar 

  32. Zink W, Seif C, Bohl JRE et al. (2002) Bupivacaine but not ropivacaine induces apoptosis in mammalian skeletal muscle fibers. Anesthesiology 96: A971

    Article  Google Scholar 

  33. Zink W, Seif C, Bohl JRE et al. (2002) The acute myotoxic effects of bupivacain and ropivacaine after continuous peripheral nerve blockades. Anesth Analg 97: 1173–1179

    Google Scholar 

  34. Zink W, Sinner B, Zausig Y,·Graf BM (2007) Myotoxizität von Lokalanästhetika. Anaesthesist 56: 118–127

    Article  PubMed  CAS  Google Scholar 

  35. Matthias Hofer (2006) CT-Kursbuch. Ein Arbeitsbuch für den Einstieg in die Computertomographie, 5. Aufl. DIDAMED, Düsseldorf, S 16

  36. Bundesinstitut für Arzneimittel und Medizinprodukte (www.bfarm.de)

  37. Arzneimittel-Kompendium der Schweiz unter Bupivacain Bioren und Bupivacain Sintetica

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  1. Institut für Anästhesie, Chirurgische Intensivmedizin, Rettungsmedizin und Schmerztherapie, Luzerner Kantonsspital, 6000, Luzern 16, Schweiz

    I. Balga, H. Gerber & C. Konrad

  2. Pathologisches Institut, Luzerner Kantonsspital, Luzern, Schweiz

    J. Diebold

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  1. I. Balga
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  2. H. Gerber
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  3. C. Konrad
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  4. J. Diebold
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Correspondence to I. Balga.

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Balga, I., Gerber, H., Konrad, C. et al. Entwicklung eines Weichteilulkus nach periduraler Langzeitinfusion. Anaesthesist 58, 156–162 (2009). https://doi.org/10.1007/s00101-008-1462-3

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  • DOI: https://doi.org/10.1007/s00101-008-1462-3

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