Anesth Analg 2005;100:365-366
© 2005 International Anesthesia Research Society
doi: 10.1213/01.ANE.0000143562.88730.0C
PEDIATRIC ANESTHESIA
Inadvertent Extra-Epidural Catheter Placement in an Infant
Darryl Berkowitz, MD*,
Robin D. Kaye, MD
,
Scott D. Markowitz, MD*
, and
Scott D. Cook-Sather, MD*
*Department of Anesthesia, Hospital of the University of Pennsylvania; and Departments of Anesthesiology and Critical Care Medicine and Radiology, The Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
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Abstract
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We report the inadvertent passage of an epidural catheter threaded from the caudal space out of a lumbar intervertebral foramen and into the lower thoracic paravertebral space in an infant. We identified the errant catheter by radiography and removed it without sequelae.
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Introduction
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Infants undergoing major thoracic surgery may benefit from epidural catheters. Citing greater ease and safety in these young patients, anesthesiologists often favor catheter placement via a caudal approach over direct thoracic-level entry (1). Thoracic-level placement may be thwarted, however, if the catheter enters an epidural vein, coils after encountering an obstruction, or exits the epidural space entirely (1–6). We report the inadvertent passage of an infant caudal catheter out of the epidural space and into the lower thoracic paravertebral space through a lumbar intervertebral foramen.
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Case Report
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A 5-wk-old, 4.9-kg male with a left congenital cystic adenomatous malformation presented for elective resection via left thoracotomy. He had been diagnosed in utero and delivered by cesarian section at 38 wk. After a 24-h elective tracheal intubation, he had been tracheally extubated and then discharged to home. On the day of surgery, his physical examination was unremarkable: breath sounds were equal and clear bilaterally and his sacral region appeared normal. Preoperative laboratory values included a platelet count of 556,000/mm3.
Routine monitors were applied and a mask placed for inhaled induction with O2, N2O, and sevoflurane. IV access was secured, vecuronium administered, and the trachea intubated. The infant was placed left side up and the caudal area was prepared with povidone-iodine solution and draped. An 18-gauge IV Insyte catheter (Becton-Dickinson, Sandy, UT) was introduced into the caudal epidural space via the sacral hiatus and the needle withdrawn. A styletted, open-end 20-gauge nylon epidural catheter (Portex, Keene, NH) was easily advanced 13 cm through the 18-gauge introducer catheter, although some transient, mild resistance was noted mid-placement. The introducer and stylet were removed and, after negative aspiration for cerebrospinal fluid and blood, the epidural catheter was incrementally dosed with 2.5 mL of 1.5% lidocaine with 1:200,000 epinephrine. No changes in heart rate (HR) or electrocardiogram configuration were noted under a maintenance anesthetic of O2/air/desflurane. The epidural catheter was bolused with 2 mL of 0.25% bupivacaine with 1:200,000 epinephrine and surgery begun. Apart from a brief increase in HR and arterial blood pressure at incision, prompting us to increase the volatile anesthetic concentration, vital signs remained stable with HR 150–155 bpm and systolic blood pressure 80–90 mm Hg. At the end of surgery, the neuromuscular blockade was reversed, desflurane was discontinued, and the infant was safely extubated. The infant was mildly irritable, but both legs were slow to move to stimulation. A routine thoracoabdominal radiograph was taken after 0.3 mL of preservative-free Omnipaque 180 (iohexol, 180 mg iodine/mL; Amershamhealth, Princeton, NJ) was injected into the epidural catheter. We were surprised to see that the epidural catheter had exited via a left L4/5 intervertebral foramen and that the catheter tip was in the left paravertebral space at the T11/12 level. Figure 1) We removed the catheter and administered IV ketorolac for postoperative analgesia. Neurologic examination revealed an apparent bilateral leg weakness that resolved within hours. The infant was made comfortable with an IV morphine infusion.
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Figure 1. A thoracoabdominal radiograph demonstrates the epidural catheter exiting the vertebral canal at L4/5 (lower arrow) and extending with a plume of contrast to the T11/12 level (upper arrow) in the left paravertebral space.
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Discussion
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Malposition of epidural catheters is described in both the adult and pediatric anesthesia literature (1–7). Although lumbar epidural catheter exit through an intervertebral foramen has been reported in adults and adolescents (7), we believe ours to be the first report of a caudal catheter exiting an intervertebral foramen in an infant. Only one other case of a catheter outside the vertebral canal—one found in the presacral space—has been reported in the infant population (4). In this latter case, it is likely that the introducer angiocatheter penetrated the sacrum and delivered the "epidural" catheter into the presacral space directly.
Why might the epidural catheter have left the lumbar vertebral canal and lodged in the paravertebral space of our infant? Two possibly interrelated mechanisms may be involved. First, anatomic obstruction in the epidural space may have caused the catheter to deviate from its initial axial trajectory. Adhesions (less likely here in an otherwise normal infant without prior instrumentation), nerve roots, and epidural dorsomedian septa may impede both drug and catheter passage (1,2,4). Second, a stiff styletted catheter may be more likely to penetrate soft tissues and to allow exit along the dural sleeve projecting with a nerve root out an intervertebral foramen. The lateral decubitus position, at least as far as gravity is concerned, would not have seemed to contribute to catheter exit, because the catheter left the vertebral canal on the nondependent side.
Could we have prevented this? Some practitioners recommend replacing the catheter if the slightest resistance is felt during placement, but in the Bösenberg et al. (1) series, 14 of 20 cases had some "slight resistance" during passage of the catheter even as 19 of 20 reached the desired level. Furthermore, ease of catheter advancement, such as that described in the presacral catheter (4), does not ensure proper placement (2,3). Although we believe that catheters should be replaced if resistance is felt early in the attempted passage, or if the resistance is persistent, we would not have changed our management in this case. Recently developed techniques for catheter placement may, with nerve stimulation guidance (8), or may not, in the case of electrocardiogram trace comparison (9), have helped us to avoid extradural placement. We agree with Valairucha et al. (6) and recommend obtaining confirmatory radiographs.
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Footnotes
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Accepted for publication August 12, 2004.
Address correspondence to Scott D. Cook-Sather, MD, Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, 34th St. and Civic Center Blvd., Philadelphia, PA 19104-4399. Address e-mail to sather{at}email.chop.edu.
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References
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- Blanco D, Llamazares J, Martinez-Mora J, Vidal F. Thoracic epidural anesthesia by the caudal route in pediatric anesthesia: age is a limiting factor [Article in Spanish]. Rev Esp Anestesiol Reanim 1994;41:214–6.[Medline]
- Blanco D, Llamazares J, Rincon R, et al. Thoracic epidural anesthesia via the lumbar approach in infants and children. Anesthesiology 1996;84:1312–6.[ISI][Medline]
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- Valairucha S, Seefelder C, Houck CS. Thoracic epidural catheters placed by the caudal route in infants: the importance of radiographic confirmation. Paediatr Anaesth 2002;12:424–8.[ISI][Medline]
- Shanks CA. Four cases of unilateral epidural analgesia. Br J Anaesth 1968;40:999–1002.[Abstract/Free Full Text]
- Tsui CH, Seal R, Koller J, et al. Thoracic epidural analgesia via the caudal approach in pediatric patients undergoing fundoplication using nerve stimulation guidance. Anesth Analg 2001;93:1152–5.[Abstract/Free Full Text]
- Tsui BC, Seal R, Koller J. Thoracic epidural catheter placement via the caudal approach in infants by using electrocardiographic guidance. Anesth Analg 2002;95:326–30.[Abstract/Free Full Text]
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Abstract
Introduction
