Anesth Analg 2006;103:1585-1586
© 2006 International Anesthesia Research Society
doi: 10.1213/01.ane.0000246446.97675.a6
LETTER TO THE EDITOR
Editor-in-Chief Steven L. Shafer
A Contraindication to Using Local Anesthetic Solution for Expanding the Epidural Space
Rajesh Mahajan, MD,
Anju Sharma, MBBS, and
Rahul Gupta, MD
Department of Anaesthesia; ASCOMS; Jammu; Jammu and Kashmir, India; drmahajanr{at}rediffmail.com or drmahajanr{at}yahoo.com
To the Editor:
We were interested in the recent study by Cesur et al. (1), in which they demonstrated the advantages of administering a high volume of local anesthetic through the epidural needle before inserting an epidural catheter. We report a complication encountered when we practiced this technique. A 50-year-old ASA-1 woman was scheduled for transabdominal hysterectomy. With the patient in the lateral position, we inserted an 18-G Tuohy needle at the L4–5 intervertebral space and advanced it using the loss-of-resistance technique, whereupon we accidentally punctured the dura. We repeated the procedure at L3–4. After confirming placement of the needle tip in the epidural space, we injected a test dose of 3 mL of 0.25% plain lidocaine with epinephrine 5 µg · mL–1. Seeing no response to the test dose, and after verifying that there was no return flow through the needle, we injected an additional 13 mL of 0.5% plain bupivacaine and smoothly inserted the epidural catheter.
Within 6–7 min, the patient had sensory anesthesia extending to the T4 dermatome, followed by hypotension and respiratory distress within the next 2 min. We administered mephentermine 6 mg and IV fluids to maintain her arterial blood pressure. We then induced general anesthesia and intubated the patient’s trachea. The patient was anesthetized, paralyzed, and the lungs were mechanically ventilated. We infused dopamine to achieve hemodynamic stability. Arterial oxygen saturation never went below 94%. Surgery proceeded uneventfully. At the conclusion of surgery, the patient awoke with adequate strength and then we extubated the patient’s trachea. She was hemodynamically stable with a sensory level at T10.
We believe the rapid onset of sensory, motor, and sympathetic blockade resulted from bupivacaine entering the intrathecal space through the dural rent. The driving force into the intrathecal space was the pressure resulting from injecting a large volume of local anesthetic. Therefore, despite the findings reported by Cesur et al. (1), expanding the dural space by injecting large volumes of local anesthetic is probably contraindicated after inadvertent dural puncture (2,3).
REFERENCES
- Cesur M, Alici HA, Erdem AF, et al. Administration of local anesthetic through the epidural needle before insertion of epidural catheter improves the quality of anesthesia and reduces catheter related complications. Anesth Analg 2005;101:1501–5.[Abstract/Free Full Text]
- Armitage EN. Lumbar and thoracic epidural block. In: Wildsmith JAW, Armitage EN, McClure JH, eds. Principles and practice of regional anesthesia. 3rd ed. Philadelphia: Churchill Livingstone, 2003:139–68.
- Cook TM. Combined spinal-epidural technique. Anaesthesia 2000;55:42–64.[Web of Science][Medline]
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M. Cesur, H. A. Alici, A. F. Erdem, F. Silbir, and M. S. Yuksek
A Contraindication to Using Local Anesthetic Solution for Expanding the Epidural Space
Anesth. Analg.,
December 1, 2006;
103(6):
1586 - 1586.
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