Case report
Case report: Subdural anesthesia in the obstetric patient
Informe de caso: Anestesia subdural en la paciente obstétrica
Carlos Andrés Palacio-Garcíaa,
, Juan Manuel Gómez-Menéndezb
Corresponding author
cpalacio65@gmail.com
Corresponding author at: Departamento de Anestesiología, Universidad del Valle, Edificio 112, Hospital Universitario del Valle, Piso 4. Campus San Fernando. Calle 5, No. 36-08, Cali, Colombia.
Corresponding author at: Departamento de Anestesiología, Universidad del Valle, Edificio 112, Hospital Universitario del Valle, Piso 4. Campus San Fernando. Calle 5, No. 36-08, Cali, Colombia.
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Campus San Fernando. Calle 5, No. 36-08, Cali, Colombia." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Informe de caso: Anestesia subdural en la paciente obstétrica" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "<span class="elsevierStyleItalic">Source</span>: Authors." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1031 "Ancho" => 1435 "Tamanyo" => 181257 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Catheter misplacement during subdural anesthesia.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Subdural anesthesia is a relatively frequent complication from neuraxial anesthesia though seldom recognized,<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">1</span></a> with a spectrum of presentation of variable severity. According to Lubenow's studies the overall incidence among the general population has been estimated at 0.87%<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">2</span></a> and in obstetric patients undergoing epidural anesthesia the incidence is estimated at 0.024%.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">3</span></a> However, in studies with contrast medium, values as high as 7–11%<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">1,4–6</span></a> have been identified. This case illustrates an unusual presentation, the risk factors involved, and the preventive actions that could be adopted.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The subdural space has been classically described as a virtual space occupied by serous fluid contained between the dura mater and the arachnoid. Consistent with this anatomical denomination it could be similar to other serous cavities such as the pericardium or the pleurae; this means two layers in contact with a serous structure that promotes friction in the absence of any intercellular bonds. However, recent studies in dead human bodies and using electron microscopy show that this space does not actually exist and if present is the result of pathologic or iatrogenic factors.<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">7–10</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Histologically speaking, the “subdural space” is made up by a neuroepithelium of elongated, spindle-shaped and branched cells with lax intercellular bonds surrounded by few collagen fibers and some blood vessels resulting in low mechanical resistance<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">11,12</span></a> (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>). The subdural space is localized between the most inner segment of the dura mater – a very tough tissue composed of 80 layers of web-shaped collagen fibers that that run in multiple directions and the arachnoid mater composed of several cellular planes connected by desmosome-type specialized narrow intercellular bonds that make it the primary barrier against the passage of substances.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">12</span></a> The subdural neuroepithelium is concentrically oriented around the dural sac and, in contrast to the epidural space, it is not limited by the foramen magnum. This is the most frail tissue inside the meninges that may sustain injuries and result in a pathological space whose size and shape are determined by the strength of the generating force and represents is a critical factor for the direction and distribution of any substances administered in that area. In the case of local anesthetic agents this accounts for the huge variability of clinical presentations.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">2,5,6</span></a> Finally the clinical presentation of the anesthetic block is determined by the meningeal structures permeated. If the dura mater is not permeated, the characteristics will mimic an epidural anesthesia but if the dura mater is disrupted while the arachnoid is preserved, the clinical presentation will resemble a subdural anesthesia. Lastly, if the arachnoid is disrupted and the anesthetic agent deposits in the subarachnoid cavity (intrathecal), the anesthesia will be spinal or subarachnoid.<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">13,14</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Case report</span><p id="par0020" class="elsevierStylePara elsevierViewall">22-year old patient, 39 weeks in her first pregnancy, 80<span class="elsevierStyleHsp" style=""></span>kg of body weight, previously healthy, scheduled for cesarean section due to a breech presentation, negative history, vital signs: Blood pressure: 110/70, heart rate: 80/Min, respiratory rate: 18/Min, body temperature: 37°C, arterial oxygen saturation: 99.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The decision was made to administer epidural anesthesia after obtaining the patient's informed consent and using non-invasive monitoring, following a strict aseptic technique, a single attempt L3–L4 Tuohy # 18 needle puncture was performed. The epidural space was identified using the loss of resistance to air technique, leaving in place a 3<span class="elsevierStyleHsp" style=""></span>cm catheter.</p><p id="par0030" class="elsevierStylePara elsevierViewall">A test dose with 3<span class="elsevierStyleHsp" style=""></span>cc of lidocaine 2%<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>100<span class="elsevierStyleHsp" style=""></span>mcg fentanyl was administered with no signs of intrathecal or intravenous injection.</p><p id="par0035" class="elsevierStylePara elsevierViewall">7<span class="elsevierStyleHsp" style=""></span>cc of lidocaine 2% and 10<span class="elsevierStyleHsp" style=""></span>cc of bupivacaine 0.5% were added to complete the volume of anesthetic. A T6 sensory level was achieved and the surgery began uneventfully.</p><p id="par0040" class="elsevierStylePara elsevierViewall">A male baby was born 12<span class="elsevierStyleHsp" style=""></span>min later with an Apgar score of 9–10.</p><p id="par0045" class="elsevierStylePara elsevierViewall">20<span class="elsevierStyleHsp" style=""></span>min into the procedure the patient developed upper limb paresthesia and respiratory distress, became anxious and the monitor then indicated the following vital signs: BP 90/60 HR 54<span class="elsevierStyleHsp" style=""></span>min<span class="elsevierStyleSup">–1</span> SaO<span class="elsevierStyleInf">2</span> 94.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Sensory block was evidenced with level C5 upper extremities involvement, with no motor block. The patient was managed with a bolus of lactated Ringer's solution and increased FiO<span class="elsevierStyleInf">2</span> and there were no major complications afterwards. The procedure was then completed with no further deterioration of the patient. No additional doses of anesthetic were required via the epidural catheter, which was then removed at the completion of surgery. The sensory block lasted for 6<span class="elsevierStyleHsp" style=""></span>h.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Discussion</span><p id="par0055" class="elsevierStylePara elsevierViewall">Different scenarios may evolve in terms of the mechanisms leading to subdural anesthesia:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0060" class="elsevierStylePara elsevierViewall">The spinal or epidural needle may perforate the dura mater and the arachnoid with the orifice located between the two spaces. In this context we must keep in mind the pressure difference since pressure is below the atmospheric pressure in the subdural tissue but positive in the CSF, giving rise to positive aspiration of CSF. However, the anesthetic injection will take the path of less resistance, i.e. the subdural space which is the mechanism accounting for failed subarachnoid anesthesia.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">8</span></a></p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0065" class="elsevierStylePara elsevierViewall">The spinal or epidural needle may perforate the dura with no involvement of the arachnoid. In this case, the CSF aspiration will be negative, while the loss of resistance in air or water will be positive and a catheter may be easily placed inside this tissue. (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>) This is the mechanism accounting for the occurrence of subdural anesthesia.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">8</span></a></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></li></ul></p><p id="par0070" class="elsevierStylePara elsevierViewall">There are some other less common mechanisms such as the multi-orifice catheters with a subdural placement of the distal end while the proximal orifices that may be placed in the epidural space. This results in a normal presentation with low rate infusions allowing for perfusion through the proximal ends; however, a bolus administration will lead to a clinical presentation of subdural anesthesia.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">15</span></a> Catheter migration is yet another mechanism.<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">8,15</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Other subdural anesthesia-associated factors have been identified with the common denominator of physically damaging the dura mater; these are:</p><p id="par0080" class="elsevierStylePara elsevierViewall">Post lumbar puncture, prior subdural injection, rotation of the epidural needle, a history of spine surgery, and repeated attempts at the same site; however, there is no relationship with the level of experience.<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">5,6,8</span></a>.</p><p id="par0085" class="elsevierStylePara elsevierViewall">The clinical presentation is quite variable, ranging from a normal presentation of epidural anesthesia, unilateral blocks, patchy blocks or involving some dermatomes, or a very high sensory block in contrast with a minimal or non-existent motor block.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">1,2,14,16</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Such heterogeneity results from the above-mentioned characteristics. The prevalence of a sensory over a motor block is due to the fact that the space is created and the access is posterior allowing selectivity of the for dorsal roots, in addition to the fact that the dura mater and the arachnoid tend to be fused on the anterior root, limiting the diffusion at this level.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">11,12</span></a> Furthermore, based on the volume and pressure used, extensive, patchy or unilateral may be expected, depending on the dissection plane that the injected fluid follows into the “subdural space”.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">11,12</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">An accurate diagnosis is made by injecting 6<span class="elsevierStyleHsp" style=""></span>cc of contrast medium and obtaining AP and lateral X-rays, or with the use of fluoroscopy or CT, delivering a characteristic subdural distribution pattern<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">1,4</span></a> (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>A–C).</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">Several signs or symptoms are suspicious of a subdural placement of the catheter or the needle; i.e., the absence or evident loss of resistance; frontal headache or pain following the application. Any of these symptoms call for a radiological confirmation of the position or changing space as a last resort. When neither of the above recommendations is feasible, quit the technique.<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">5,6</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">In terms of the test dose typically used, such dose is of little use for identifying subdural anesthesia.<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">8,9,17,18</span></a> However, the use of the neurostimulator has been considered useful because a response below 1<span class="elsevierStyleHsp" style=""></span>mA when the localization is in the subdural space gives a diffuse response with the involvement of multiple dermatomes, while if the localization is in the epidural space with stimuli between 1 and 10<span class="elsevierStyleHsp" style=""></span>mA, the responses obtained will correspond to the dermatome where the needle is placed.<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">16,19</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Hoftman and Ferrante<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">1</span></a> recently developed some diagnostic criteria for subdural anesthesia without imaging, using as major criteria for the epidural technique the negative outflow of CSF associated to tactile sensation due to loss of resistance and they suggest two scenarios: excessive or restricted block. In each case, the following minor criteria are considered, though one is enough to make a diagnosis:</p><p id="par0115" class="elsevierStylePara elsevierViewall">For excessive block (93% sensitivity) the criteria are: starts after more than 20<span class="elsevierStyleHsp" style=""></span>min, cardiovascular stability, sensory involvement with minimum or absent motor activity, patchy or asymmetrical distribution, respiratory failure and head or face anesthesia.</p><p id="par0120" class="elsevierStylePara elsevierViewall">In the case of restricted block (sensitivity 100%), the criteria include a start after more than 20<span class="elsevierStyleHsp" style=""></span>min and sensory involvement with minimum or absent motor effect.</p><p id="par0125" class="elsevierStylePara elsevierViewall">In terms of the subarachnoid technique, Hoftman and Ferrante<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">1</span></a> say that in the presence of tactile sensation of a subarachnoid puncture and CSF leak as major criterion, one of the following conditions is enough to make the diagnosis: excessive (no cases reported), restricted (sensitivity 100%), start beyond 20<span class="elsevierStyleHsp" style=""></span>min, sensitive involvement with minimal or absent motor effect and failed block.</p><p id="par0130" class="elsevierStylePara elsevierViewall">No deaths have been reported due to subdural block. Management is based on support therapy, atropine for bradycardia control, crystalloids or colloids boluses for hypotension, trendelemburg position, and vasopressors if needed. Ventilation support may be required and although some subdural catheters may behave normally, the recommendation is to remove them due to their unpredictable nature.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">5</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Although the patient did not report any symptoms such as headache or pain upon advancing the catheter, nor was the loss of resistance during the identification of the epidural space reported as “vague”, all of these signs and symptoms are too subtle. Additionally, saline solution instead of air shall be used for the identification of the epidural space, since according to a recent meta-analysis the former has been associated with less post-puncture headaches and fewer attempts.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">20</span></a> It should be noted that the number of attempts and post-puncture headaches are associated with meningeal lesions, a critical event in subdural anesthesia.<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">11,12</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conclusion</span><p id="par0140" class="elsevierStylePara elsevierViewall">Notwithstanding the fact that the diagnosis of subdural block is confirmed radiologically using the above-mentioned criteria, there is evidence of good diagnostic sensitivity based on clinical criteria. In our case, according to Hoffman's criteria, the sensitivity was 93%. There were no incidents alerting us about a subdural localization during the catheter insertion. However, we should be attentive to these signs and symptoms and in case of doubt proceed with a radiological verification, use the neurostimulator, and when neither of these options is available, change the intervertebral space or the anesthetic/analgesic technique.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Ethical disclosures</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Protection of human and animal subjects</span><p id="par0170" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Confidentiality of data</span><p id="par0175" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Right to privacy and informed consent</span><p id="par0180" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Funding</span><p id="par0145" class="elsevierStylePara elsevierViewall">The authors did not receive sponsorship to carry out this article.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflict of interest</span><p id="par0150" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres631153" "titulo" => "Abstract" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Case presentation" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec644005" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres631152" "titulo" => "Resumen" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0020" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0025" "titulo" => "Presentación del caso" ] 2 => array:2 [ "identificador" => "abst0030" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec644006" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusion" ] 8 => array:3 [ "identificador" => "sec0040" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0045" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0050" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0055" "titulo" => "Right to privacy and informed consent" ] ] ] 9 => array:2 [ "identificador" => "sec0025" "titulo" => "Funding" ] 10 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflict of interest" ] 11 => array:2 [ "identificador" => "xack212730" "titulo" => "Acknowledgements" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-10-10" "fechaAceptado" => "2016-01-28" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec644005" "palabras" => array:5 [ 0 => "Subdural space" 1 => "Anesthesia, epidural" 2 => "Cesarean section" 3 => "Autonomic nerve block" 4 => "Risk factors" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec644006" "palabras" => array:5 [ 0 => "Espacio subdural" 1 => "Anestesia epidural" 2 => "Cesárea" 3 => "Bloqueo nervioso autónomo" 4 => "Factores de riesgo" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Subdural anesthesia is a relatively frequent complication though seldom recognized. It has a broad spectrum of presentations ranging from an unexpectedly high sensory block with limited motor block, to substantial hemodynamic and respiratory involvement.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Case presentation</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A 22-year old woman undergoing cesarean section under epidural anesthesia with evidence of long-lasting higher than expected sensory block and respiratory distress.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conclusion</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Neuraxial anesthesia comprises a number of versatile and safe techniques, though not exempt from complications including subdural anesthesia. We should be aware of this possibility in our clinical practice, know the risk factors and the diagnostic criteria.</p></span>" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Case presentation" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Introducción</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">La anestesia subdural es una complicación de la anestesia neuroaxial relativamente frecuente pero poco reconocida, tiene un espectro de presentación bastante amplio que va desde un bloqueo sensitivo inesperadamente alto con poco bloqueo motor, hasta compromiso hemodinámico y respiratorio importante.</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Presentación del caso</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Mujer de 22 años que es llevada a cesárea con anestesia epidural, con evidencia de bloqueo sensitivo más alto de lo esperado, de larga duración y dificultad respiratoria.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusión</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La anestesia neuroaxial es un conjunto de técnicas versátiles y seguras, aunque no exentas de complicaciones como lo es la anestesia subdural. En la práctica clínica debemos estar atentos a esta posibilidad, conocer los factores de riesgo y los criterios diagnósticos.</p></span>" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "abst0020" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0025" "titulo" => "Presentación del caso" ] 2 => array:2 [ "identificador" => "abst0030" "titulo" => "Conclusión" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Palacio-García CA, Gómez-Menéndez JM. Informe de caso: Anestesia subdural en la paciente obstétrica. Rev Colomb Anestesiol. 2016;44:174–178.</p>" ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "<span class="elsevierStyleItalic">Source</span>: Authors." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1180 "Ancho" => 1650 "Tamanyo" => 230474 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Graphical representation of the meningeal epithelia and their relationship to the subdural neuroepithelium.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "<span class="elsevierStyleItalic">Source</span>: Nephron <a class="elsevierStyleInterRef" id="intr0005" href="https://goo.gl/DDG616">https://goo.gl/DDG616</a>. Reproduction with permission." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1100 "Ancho" => 1650 "Tamanyo" => 447035 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Subdural hematoma seen under optic microscopy to identify the plane of separation of the neuroepithelium.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "<span class="elsevierStyleItalic">Source</span>: Authors." "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1031 "Ancho" => 1435 "Tamanyo" => 181257 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Catheter misplacement during subdural anesthesia.</p>" ] ] 3 => array:8 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "<span class="elsevierStyleItalic">Source</span>: Authors." 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 15 | 6 | 21 |
| 2024 October | 166 | 10 | 176 |
| 2024 September | 144 | 10 | 154 |
| 2024 August | 212 | 17 | 229 |
| 2024 July | 213 | 14 | 227 |
| 2024 June | 140 | 9 | 149 |
| 2024 May | 169 | 18 | 187 |
| 2024 April | 130 | 22 | 152 |
| 2024 March | 167 | 7 | 174 |
| 2024 February | 248 | 27 | 275 |
| 2024 January | 220 | 19 | 239 |
| 2023 December | 194 | 9 | 203 |
| 2023 November | 188 | 16 | 204 |
| 2023 October | 194 | 16 | 210 |
| 2023 September | 140 | 8 | 148 |
| 2023 August | 97 | 17 | 114 |
| 2023 July | 80 | 10 | 90 |
| 2023 June | 103 | 10 | 113 |
| 2023 May | 83 | 9 | 92 |
| 2023 April | 70 | 6 | 76 |
| 2023 March | 78 | 5 | 83 |
| 2023 February | 67 | 18 | 85 |
| 2023 January | 55 | 6 | 61 |
| 2022 December | 79 | 6 | 85 |
| 2022 November | 68 | 8 | 76 |
| 2022 October | 46 | 15 | 61 |
| 2022 September | 66 | 5 | 71 |
| 2022 August | 70 | 20 | 90 |
| 2022 July | 70 | 9 | 79 |
| 2022 June | 72 | 14 | 86 |
| 2022 May | 74 | 8 | 82 |
| 2022 April | 70 | 24 | 94 |
| 2022 March | 86 | 16 | 102 |
| 2022 February | 113 | 10 | 123 |
| 2022 January | 126 | 17 | 143 |
| 2021 December | 83 | 13 | 96 |
| 2021 November | 83 | 13 | 96 |
| 2021 October | 93 | 12 | 105 |
| 2021 September | 70 | 8 | 78 |
| 2021 August | 63 | 14 | 77 |
| 2021 July | 24 | 13 | 37 |
| 2021 June | 39 | 10 | 49 |
| 2021 May | 93 | 5 | 98 |
| 2021 April | 203 | 29 | 232 |
| 2021 March | 122 | 18 | 140 |
| 2021 February | 75 | 13 | 88 |
| 2021 January | 111 | 11 | 122 |
| 2020 December | 126 | 20 | 146 |
| 2020 November | 101 | 19 | 120 |
| 2020 October | 61 | 12 | 73 |
| 2020 September | 29 | 12 | 41 |
| 2020 August | 54 | 21 | 75 |
| 2020 July | 34 | 8 | 42 |
| 2020 June | 24 | 5 | 29 |
| 2020 May | 36 | 11 | 47 |
| 2020 April | 29 | 3 | 32 |
| 2020 March | 20 | 1 | 21 |
| 2020 February | 17 | 6 | 23 |
| 2020 January | 23 | 7 | 30 |
| 2019 December | 21 | 3 | 24 |
| 2019 November | 4 | 4 | 8 |
| 2019 October | 6 | 3 | 9 |
| 2019 September | 5 | 1 | 6 |
| 2019 August | 1 | 2 | 3 |
| 2019 July | 4 | 7 | 11 |
| 2019 June | 2 | 0 | 2 |
| 2019 May | 0 | 9 | 9 |
| 2019 April | 1 | 0 | 1 |
| 2018 December | 1 | 0 | 1 |
| 2018 September | 1 | 0 | 1 |
| 2018 June | 6 | 4 | 10 |
| 2018 May | 42 | 9 | 51 |
| 2018 April | 38 | 8 | 46 |
| 2018 March | 27 | 7 | 34 |
| 2018 February | 24 | 9 | 33 |
| 2018 January | 21 | 6 | 27 |
| 2017 December | 32 | 6 | 38 |
| 2017 November | 31 | 7 | 38 |
| 2017 October | 25 | 15 | 40 |
| 2017 September | 32 | 8 | 40 |
| 2017 August | 24 | 5 | 29 |
| 2017 July | 22 | 6 | 28 |
| 2017 June | 32 | 4 | 36 |
| 2017 May | 41 | 11 | 52 |
| 2017 April | 39 | 10 | 49 |
| 2017 March | 35 | 6 | 41 |
| 2017 February | 38 | 1 | 39 |
| 2017 January | 12 | 6 | 18 |
| 2016 December | 44 | 9 | 53 |
| 2016 November | 30 | 11 | 41 |
| 2016 October | 57 | 9 | 66 |
| 2016 September | 107 | 8 | 115 |
| 2016 August | 48 | 8 | 56 |
| 2016 July | 28 | 11 | 39 |
| 2016 May | 4 | 22 | 26 |
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