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LETTER TO THE EDITOR

A Contraindication to Using Local Anesthetic Solution for Expanding the Epidural Space

Department of Anesthesiology and Reanimation; Medical Faculty; Atatürk University; Erzurum, Turkey; mcesur{at}atauni.edu.tr

In Response:

We thank Mahajan et al. (1) for their interest in our study (2). Epidural anesthesia after dural puncture does raise concern about the possibility of profound levels of spinal anesthesia from leakage of the epidurally administered local anesthetic through the dural hole into the subarachnoid space. There are anecdotal case reports and some studies supporting this concern (3). Bernards et al (4) demonstrated that influx is directly proportional to the size of the dural puncture and inversely proportional to the distance of the dural puncture from the site of epidural drug administration.

This concern is particularly relevant for the combined spinal-epidural technique (CSE), because this technique includes an intentional dural puncture and a bolus epidural injection. Indeed, some authors thought that the dural hole created during the CSE technique, without subarachnoid drug administration, might increase subarachnoid transfer of epidurally administered drugs, thus improving the epidural analgesia. However, the clinical significance of these proposed effects during CSE labor analgesia has not been demonstrated (5–7).

As for the authors’ case, there are some confusing factors:

1. Their test dose (3 mL of 0.25% [i.e., 7.5 mg] plain lidocaine) was low. According to Moore and Batra (8), the test dose should be at least 45 mg.
   
2. The rapid onset suggests direct subarachnoid injection. The lack of freely flowing cerebrospinal fluid from the epidural needle does not exclude direct subarachnoid injection.
   
3. The authors mention injection of 13 mL of local anesthetic solution. In our view, the total dose should be injected in divided doses and slowly.
   
4. We did not know whether apnea, unconsciousness, and dilated pupils were seen as a result of the action of local anesthetic on the brainstem and how long those symptoms lasted in that case because general anesthesia was administered.
   

We consider the case described by Dr. Mahajan et al. a cautionary note, and not a contraindication. Leakage of epidural local anesthetic through a dural rent must be kept in mind, and perhaps it would be prudent in such a setting to decrease the dose (e.g., by approximately 25%) and be careful to give the dose incrementally, avoiding any injection pressure.

REFERENCES

1. Mahajan, R, Sharma A, Gupta R. A contraindication to using local anesthetic solution for expanding the epidural space. Anesth Analg 2006;103:1585–6.[Free Full Text]
2. 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]
3. Cook TM. Combined spinal-epidural techniques. Anaesthesia 2000:55;42–64.[Web of Science][Medline]
4. Bernards C, Kopacz D, Michel M. Effect of needle puncture on morphine and lidocaine flux through the spinal meninges of the monkey. Anesthesiology 1994:80;853–8.[Web of Science][Medline]
5. Suzuki N, Koganemaru M, Onizuka S, Takasaki M. Dural puncture with a 26-gauge spinal needle affects spread of epidural anesthesia. Anesth Analg 1996;82:1040–2.[Abstract]
6. Swenson JD, Lee TH, McJames S. The effect of prior dural puncture on cerebrospinal fluid sufentanil concentrations in sheep after the administration of epidural sufentanil. Anesth Analg 1998:86;794–6.[Abstract]
7. Thomas JA, Pan PH, Harris LC, et al. Dural puncture with a 27-gauge whitacre needle as part of a combined spinal-epidural technique does not improve labor epidural catheter function. Anesthesiology 2005:103;1046–51.[Web of Science][Medline]
8. Moore DC, Batra MS. The components of an effective test dose prior to epidural block. Anesthesiology 1981:55;693–6.[Web of Science][Medline]

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