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REGIONAL ANESTHESIA

Unintentional Intrapleural Insertion of an Epidural Catheter: Should We Remove It or Leave It In Situ to Provide Perioperative Analgesia?

Department of Anesthesiology, Nara Medical University, Kashihara, Nara, Japan

Address correspondence and reprint requests to Satoki Inoue, MD, Department of Anesthesiology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8522, Japan. Address e-mail to seninoue{at}naramed-u.ac.jp

	Abstract

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We report three patients who had intrapleural insertion of an intended thoracic epidural catheter. These misplaced catheters were used for local anesthetic administration. Bupivacaine injection via these catheters in two cases was effective for reducing postoperative pain. We conclude that if an intended thoracic epidural catheter is found to be in the intrapleural cavity at the time of surgery and if correct replacement of the catheter into the epidural space is not believed to be feasible after surgery, then the administration of local anesthetic through the intrapleural catheter could be considered as a potential alterative analgesic method.

IMPLICATIONS: In cases in which an intended thoracic epidural catheter is found to be in the intrapleural cavity at the time of surgery, the administration of local anesthetic through the intrapleural catheter could be a potential alterative postoperative analgesic method.

	Introduction

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Thoracic epidural analgesia is widely used for anesthetic and postoperative pain management of thoracotomy (1); however, several complications have been also reported, including dural puncture, injury to spinal cord or nerves, and formation of epidural hematoma or abscess. Intrapleural insertion of an epidural catheter is one technique-related complication (2–4). However, intrapleural placement of a catheter has been reported as an alternative or additional method of analgesic management for thoracic traumatic and surgical patients, although we cannot deny the disadvantages/complications of intrapleural analgesia (IPA), including increased local anesthetic blood levels, possibly toxic, with relatively large doses and an inferior analgesic effect compared with epidural administration (5–10). We have experienced 3 cases that had an unintentional intrapleural insertion of an epidural catheter in the last 10 years. We report here their different perioperative outcomes.

	Case Report

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All patients had an epidural catheter inserted before general anesthetic induction. The catheter insertion was performed by using the loss-of-resistance technique combined with a paramedian approach at the T5-6, T6-7, or T7-8 interspace. The epidural catheter was advanced 5 cm beyond the introducer needle tip. General anesthesia was maintained with a continuous infusion of propofol 3–5 mg · kg^–1 · h^–1 and 50%–100% oxygen and an 8-mL bolus epidural injection of 1% lidocaine followed by a 5 mL/h continuous infusion. Some technical difficulties were encountered during catheter placement. A test dose of 1% lidocaine 3 mL was administered to exclude unintentional subarachnoid injection. However, a neural blockade by epidural injection of local anesthetics was not confirmed in any of these cases before the induction of general anesthesia because difficulty with catheter placement had resulted in considerable delay of the surgery. Postoperative pain assessment and treatment were performed according to the institutional standard practice. A visual analog scale (VAS) on a 10-cm scale of 0 to 10, with 0 referring to no pain and 10 referring to unbearable pain, was used for pain assessment. Postoperative pain was assessed every 8 h, and the need for supplemental or alternative analgesia was determined by a VAS score of 6 or whenever the patient required it in the assessment interval. As supplemental or alternative analgesia, the institutional guideline for postoperative management basically recommended bolus injection of 50 mg of flurbiprofen (a nonsteroidal antiinflammatory drug) or continuous IV infusion of fentanyl (25 - 30 µg/h) according to the situation. Postoperative pain service was provided for 3 days, and the catheter was removed on the third postoperative day.

Case 1
A 67-yr-old woman (weight, 67 kg; height, 157 cm) was scheduled for right upper lobe wedge resection with a video-assisted thoracoscopic technique for biopsy. During the surgical procedure, there was no specific sign to show insufficient analgesia. After wedge resection, a surgeon found the epidural catheter in the right pleural cavity. After discussion about whether we should remove it or leave it in situ, the catheter was left there. Thereafter, a 20-mL bolus of 0.25% bupivacaine followed by a 3 mL/h continuous infusion (0.125% bupivacaine) was administered. All VAS scores were <6; no additional analgesic was administered. Postoperative analgesia was effective without any bolus injection of local anesthetics.

Case 2
A 69-yr-old man (weight, 81 kg; height, 167 cm) was scheduled for right lower lobectomy with thoracotomy for possible lung cancer. After skin incision and thoracotomy, supplemental use of fentanyl and sevoflurane was necessary to maintain the stability of his vital signs, including arterial blood pressure and heart rate. During the surgical procedure, the surgeon reported the epidural catheter to be in the right pleural cavity. Thereafter, a 20-mL bolus of 0.25% bupivacaine followed by a 3 mL/h continuous infusion (0.125% bupivacaine) was performed. Just after emergence from anesthesia, the patient complained of severe pain, and an intrapleural bolus injection (20 mL of 0.25% bupivacaine) combined with 30 min of chest tube clamp was performed. However, because the VAS score was minimally changed (from 9 to 7), continuous IV infusion of fentanyl (30 µg/h) was required in addition to intrapleural bolus injection (20 mL of 0.25% bupivacaine) combined with 30 min of chest tube clamp every 6 h. After the supplemental treatment, the VAS scores were maintained <6.

Case 3
A 72-yr-old man (weight, 72 kg; height, 160 cm) was scheduled for right lower lobectomy with thoracotomy. After skin incision and thoracotomy, an additional 8-mL bolus epidural injection of 1% lidocaine followed by a rate change of continuous epidural infusion up to 8 mL/h was effective in maintaining the stability of his vital signs. During the surgical procedure, the surgeon noted the epidural catheter to be in the right pleural cavity. Thereafter, a 20-mL bolus of 0.25% bupivacaine with 2 mg of morphine followed by a 3 mL/h continuous infusion (0.125% bupivacaine) with morphine 0.125 mg/h was delivered through the catheter. Upon emergence from general anesthesia, the patient complained of mild pain. Immediately, an intrapleural bolus injection (20 mL of 0.25% bupivacaine) combined with 30 min of chest tube clamp was performed and appeared to be effective (the VAS score of 6 changed to 3). Bolus injection (20 mL of 0.25% bupivacaine) combined with 30 min of chest tube clamp was performed every 6 h after surgery. The VAS scores were maintained at 3 to 4, and supplemental analgesia was not required.

	Discussion

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Several cases of intrapleural insertion of the epidural catheter have been reported, although this type of catheter misplacement is rare (2–4). Although it is difficult to estimate the incidence of intrapleural insertion during intended thoracic epidural catheter placement, these 3 incidents were detected among more than 1000 cases. However, these cases were reported because the catheters migrated into the ipsilateral cavity. Otherwise, they would not have been detected. It has been speculated that the inability to identify superficial landmarks and the inappropriate insertion angle of the Tuohy needle during epidural catheterization during paramedian epidural catheterization contribute to catheter misplacement (2,3). We used the paramedian method to approach the epidural space in all three patients, who were mildly obese (body mass index, 27–29 kg/m²). Demonstrating a neural blockade may be useful for early detection of epidural catheter misplacement because the two major methods for identifying the epidural space—the loss-of-resistance and hanging-drop techniques—cannot distinguish the pleural cavity from the epidural space (2,4). Preoperative evidence of neural blockade representative of epidural injection of local anesthetic was not established in any of these cases in which the catheter was located in the intrapleural cavity during surgery.

These three cases had different perioperative outcomes. We decided to leave the catheters in the pleural cavity and to use them as IPA. It is controversial to use intrapleural catheterization as the first choice for thoracic analgesia. In addition, IPA, even with large doses of bupivacaine, has been reported as insufficient, despite a large plasma bupivacaine concentration (7). Therefore, correct replacement of the thoracic epidural catheter after surgery should be confirmed, although it is also favorable to use the intrapleural method as an alternative when epidural analgesia cannot be performed (5,8). In our first case, for minimally invasive surgery combined with a thoracoscopic technique, the IPA with a small dose of bupivacaine was effective perioperatively. It has been reported that IPA is a good application for thoracic minimally invasive surgery (6). However, IPA, even with a large dose of bupivacaine, was not effective perioperatively in the second case with open thoracotomy. Several studies have demonstrated a lack of efficacy of intrapleural local anesthetics for analgesia after thoracotomy (9,10). Interestingly, this method of analgesia was effective perioperatively in the third case, although additional bolus injections and a larger dose of continuous infusion of bupivacaine were frequently required. The only difference in this method of analgesia between these two cases was the additional use of intrapleural morphine. However, intrapleural morphine has not been reported to be superior to systemic morphine (11). Adding epinephrine to bupivacaine might have improved postoperative analgesia in the second case (12).

Previous authors have recommended removal of intrapleural catheters after intended epidural placement, with subsequent replacement into the epidural space (2,4). We agree that the analgesic effect of the intrapleural method is less reliable than epidural administration and provides insufficient analgesia in some cases. However, the intrapleural method can be used and is recommended as an alternative when epidural analgesia cannot be performed (5,8). As shown in the third case, this method worked well, especially for postoperative pain management. Thus, we conclude that in cases in which an intended thoracic epidural catheter is in the intrapleural cavity at the time of surgery, the administration of local anesthetic through the intrapleural catheter could be considered as a potential alterative postoperative analgesic method after thoracotomy or thoracostomy.

	References

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1. Peeters-Asdourian C, Gupta S. Choices in pain management following thoracotomy. Chest 1999; 115: 122S–4.[Abstract/Free Full Text]
2. Furuya A, Matsukawa T, Ozaki M, Kumazawa T. Interpleural misplacement of an epidural catheter. J Clin Anesth 1998; 10: 425–6.[Web of Science][Medline]
3. Shime N, Shigemi K, Hosokawa T, Miyazaki M. Intrathoracic migration of an epidural catheter. J Anesthesia 1991; 5: 100–2.
4. Koch J, Nielsen JU. Rare misplacements of epidural catheters. Anesthesiology 1986; 65: 556–7.[Web of Science][Medline]
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6. Mehta Y, Swaminathan M, Mishra Y, Trehan N. A comparative evaluation of intrapleural and thoracic epidural analgesia for postoperative pain relief after minimally invasive direct coronary artery bypass surgery. J Cardiothorac Vasc Anesth 1998; 12: 162–5.[Web of Science][Medline]
7. Elman A, Debaene B, Magny-Metrot C, Murciano G. Interpleural analgesia with bupivacaine following thoracotomy: ineffective results of a controlled study and pharmacokinetics. J Clin Anesth 1993; 5: 118–21.[Web of Science][Medline]
8. Riegler FX. Con: unreliable benefit after thoracotomy—epidural is a better choice. J Cardiothorac Vasc Anesth 1996; 10: 429–31.[Web of Science][Medline]
9. Schneider RF, Villamena PC, Harvey J, et al. Lack of efficacy of intrapleural bupivacaine for postoperative analgesia following thoracotomy. Chest 1993; 103: 414–6.[Abstract/Free Full Text]
10. Ferrante FM, Chan VW, Arthur GR, Rocco AG. Interpleural analgesia after thoracotomy. Anesth Analg 1991; 72: 105–9.[Abstract/Free Full Text]
11. Welte M, Haimerl E, Groh J, et al. Effect of interpleural morphine on postoperative pain and pulmonary function after thoracotomy. Br J Anaesth 1992; 69: 637–9.[Abstract/Free Full Text]
12. Gin T, Chan K, Kan AF, et al. Effect of adrenaline on venous plasma concentrations of bupivacaine after interpleural administration. Br J Anaesth 1990; 64: 662–6.[Abstract/Free Full Text]

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Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999