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Print version ISSN 0034-7094
Rev. Bras. Anestesiol. vol.52 no.1 Campinas Jan./Feb. 2002
Displaced epidural catheter: a reason for analgesia failure. Case report *
Catéter peridural deslocado: una causa de falla de analgesia. Relato de caso
Guilherme Sudbrack, M.D.I; Karl Otto Geier, M.D.II
IIMédico Colaborador da Clindor/PUCRS
BACKGROUND AND OBJECTIVES:
Epidural catheter migration is a rare event. However, when post local anesthetic
injection conductive blockade is not obtained it is to be suspected that the
catheter is not in the desirable site. This report aimed at describing a case
of epidural catheter migration (L3-L4) to the right greater
psoas muscle, which was radiologically confirmed.
CASE REPORT: Female patient, 58 years of age, with obliterating thromboangiitis, submitted to left hallux amputation under combined spinal-epidural anesthesia. Spinal puncture was performed at L4-L5 and the epidural catheter was inserted at L3-L4 aiming at postoperative patient-controlled epidural analgesia (PCA). Since there were no postoperative PCA results, there was a suspicion of epidural catheter migration, which was radiologically confirmed. The catheter crossed the intervertebral foramen and was lodged in the right greater psoas muscle.
CONCLUSIONS: The absence of effects after repeated analgesic injections through the epidural catheter led to the suspicion that it was not properly placed. A radiological exam with contrast confirmed the diagnosis.
Key Words: ANALGESIA, Postoperative: patient-controlled analgesia; COMPLICATIONS: failure
JUSTIFICATIVA Y OBJETIVOS:
La migración del catéter peridural es una ocurrencia rara. Sin embargo,
cuando no se obtiene bloqueo conductivo después de inyección de anestésico
local a través del mismo, se debe sospechar que él no esté en
el local esperado. El objetivo de este relato es describir un caso de migración
de catéter peridural (L3-L4) para el interior del
músculo psoas mayor derecho, confirmado radiológicamente.
RELATO DE CASO: Paciente femenina con 58 años, portadora de tromboangiitis obliterante fue sometida a amputación del hallux izquierdo bajo técnica combinada raqui-peridural. La punción subaracnóidea fue hecha en L4-L5 y el catéter peridural fue pasado en L3-L4 con el objetivo de hacer analgesia controlada por el paciente (ACP), por vía peridural, en el pós-operatorio. Como la ACP no presentó resultados en el pós-operatorio, se sospechó de migración del catéter peridural que fue confirmada por estudio radiográfico contrastado. El catéter salió por el foramen intervertebral y quedó alojado en el músculo psoas mayor derecho.
CONCLUSIONES: La ausencia de efectos después de inyecciones repetidas de soluciones analgésicas a través de catéter peridural hace sospechar que el mismo no esté en el local apropiado. Estudio radiológico con contraste puede confirmar el diagnóstico.
Epidural catheters aiming at catheterizing the epidural space, but which inadvertently reached the intervertebral foramen 1, the pleural cavity 2, or the intraperitoneal cavity 3 are rare events. However, when it happens, the prompt diagnosis is difficult. When the presumable analgesic/anesthetic onset goes beyond usual time without conductive blockade the suspicion should be either local anesthetics validity or catheter malpositioning.
This report aimed at describing a case of postoperative lumbar epidural analgesia with infusion pump (patient-controlled analgesia - PCA) in a patient with left lower limb obliterating thromboangiitis and submitted to hallux amputation. The catheter, introduced 10 cm, exited the epidural space (L3-L4) through the intervertebral foramen to the right greater psoas muscle, which was radiologically confirmed.
Female patient, 58 years of age, with obliterating thromboangiitis, with smoking history and circulatory problems in both lower limbs, but more pronounced in the left leg. Patient was referred to the hospitals pain department with left foot ischemic suffering. After treatment with several sympatholyses, the disease was limited to the hallux with clear signs of ischemic necrosis.
Patient was submitted to left hallux amputation under combined spinal-epidural anesthesia for the surgery and epidural catheter for Patient-Controlled Analgesia by double lumbar puncture in different spaces. Surgical preparation consisted of peripheral venous access with an 18G catheter, 1000 ml saline and monitoring by continuous ECG (DII), pulse oximetry and non-invasive blood pressure. Target intervertebral spaces were infiltrated with 1% lidocaine in the sitting position. Spinal anesthesia was induced with a 25G Quincke needle and 1,5 ml (75 mg) of 5% hyperbaric lidocaine, with the bevel longitudinal to the dura at L4-L5, immediately followed by epidural puncture with an 18G Tuhoy needle, compatible catheter and antimicrobial filter (Portex Kit) in L3-L4. During beginning of 5 to 10 cm catheter introduction a mild and transient resistance with discrete right leg and foot paresthesia was observed.
Patient was sedated with fractionated 4.5 mg midazolam during the 20 minutes of surgery without any hemodynamic change. Postoperatively, Patient-Controlled Analgesia with 180-minutes intervals between 6 ml bolus doses with a mixture of 15 mg bupivacaine and 10 µg fentanyl was prepared, connected to the catheter and the patient was duly oriented on how to use the pump. Beginning of analgesia would be self-commanded at the first painful symptom during recovery. With lower limbs motility recovered and in the presence of pain (VAS ³ 6), the first two bolus doses had no effect and analgesia was replaced by intravenous titrated morphine. An immediate radiographic evaluation was performed and confirmed catheters malpositioning (Figure 1a and 1b) (Figure 2a and 2b). The catheter was replaced and Patient-Controlled Analgesia worked without problems for the next 5 days.
Obliterating thromboangiitis, or Buergers disease, is a peripheral vasculopathy mediated by sympathetic nervous system hyperactivity. It may start on lower limbs by intermittent claudication and/or on upper limbs, as in Raynauds syndrome 3. Triggering and worsening causes are trauma, cold and especially smoking. Chemical peripheral angiotomes sympathectomy 4,5, chemical peripheral sympathectomy (sympathiolysis) 6 by Biers intravenous technique associated to local anesthetics and guanetidine (pre-synaptic and post-ganglionary sympathicolytic), lumbar paravertebral neurolitic sympathectomy and lumbar epidural blockade are procedures chosen to replace surgical sympathectomy. Ruling out worsening causes should be additional to ischemia preventive and/or therapeutic measures of the schemic episode. Epidural catheterization failures are related to spinal anatomic abnormalities, to posture 1, to the technique (including needle and angulation) 7,8, to epidural space identification 1 and, in general, to excessive catheter insertion in adults 9. Lumbar epidural catheters progression in pediatrics is limited to the lumbar level under the most different techniques 10, but several authors have obtained a perfect positioning, without coiling and knot, and accessing the sacral region toward lumbar and thoracic regions 11,12. In fact, the incidence of such events is low when puncture angle is around 120º to 135º in sites where the space is smaller and narrower, such as in this group of patients, even when excessively introduced, as opposed to adults.
Patients epidural catheter was accidentally introduced inside the right greater psoas muscle after crossing the intervertebral foramen (Figure 1a and 1b, Figure 2a and 2b) with paresthetic manifestations on right distal leg and foot.
Lower limbs are innervated by the lumbosacral plexus which is composed of lumbar plexus, represented by the femoral nerve (L2-4) and its branch, the internal saphenous nerve, cutaneous lateral femoral (L2-L3), obturator (L2-L4), the inconstant accessory obturator (L2-L3), genitofemoral (L1-L2) and its genital and femoral branches, and by the sacral plexus, constituted of the sciatic nerve (L4-S3) and its branches, the tibial nerve (L4-L5-S1-S2), cutaneous posterior femoral (S1-S3) and common peroneal nerve (L4-L5-S1-S2), cutaneous posterior femoral (S1-S3). Legs and feet are mainly innervated by the sciatic nerve with medial contribution of the internal saphenous nerve. Posterior lumbosacral epidural anesthesia in bolus 13 or continuous infusion 14,15 allows for lower limb and hallux anesthesia/analgesia, as opposed to anterior lumbosacral anesthesia 16. If the epidural catheter were inserted in space between psoas major and quadratus lumborum muscles, certainly postoperative analgesia would be different. Patient-Controlled Analgesia would have good results and catheter malpositioning would not be investigated, although the potential risk for local myotoxicity due to high volume and concentration of local anesthetics with epinephrine in contact with muscle fibers 17.
Post-epidural catheterization problems, such as catheter migration outside the space 18 or intravascular 19, result in analgesia/anesthesia failure, as opposed to spinal space catheterization 20, resulting in an intense anesthesia with short onset and long area due to the involvement of several metamers. Anyway, medial and paramedial access from the sacral to the cervical region, puncture angle, space identification method, bevel orientation in the epidural space, type of catheter and length of introduction 21 are possible causes for the malpositioning of epidural catheters.
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to Submitted for publication February 16, 2001 * Received from Serviço
de Dor do Hospital São Lucas da Pontifícia Universidade Católica
do Rio Grande do Sul, RS
Dr. Karl Otto Geier
Rua Cel. Camisão, 172
90540-030 Porto Alegre, RS
Accepted for publication July 23, 2001
Submitted for publication February 16, 2001
* Received from Serviço de Dor do Hospital São Lucas da Pontifícia Universidade Católica do Rio Grande do Sul, RS