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LETTER TO THE EDITOR

Large Subcutaneous Fluid Collection Attributed to Suspected Epidural Catheter Leak

Department of Anesthesia and Pain Management, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada (Whitty) Department of Medical Imaging, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada (Lazinski) Departments of Anesthesia and Pain Management and Obstetrics and Gynecology, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada, jose.carvalho{at}uhn.on.ca (Carvalho)

To the Editor:

We report the case of a large volume of fluid infused into the subcutaneous tissue of the back due a presumed breach in an epidural catheter used for labor analgesia and cesarean delivery.

We were consulted 4 days postpartum, because of a continuous leak of clear fluid from an epidural needle puncture site. The fluid was positive for glucose, but in the lower range. No signs of edema or inflammation were observed in the surrounding tissues. A communicating fistula between the intrathecal sac and the skin was suspected. The puncture wound was sutured and antibiotics were begun while the patient was scheduled to have a magnetic resonance imaging (MRI) examination. The MRI, contrary to expectations, showed a localized subcutaneous fluid collection that extended over five vertebral levels, but no fistula (Fig. 1).

View larger version (154K): [in this window] [in a new window]   Figure 1. Sagittal T2 fat-saturated sequences of the lumbar spine, demonstrating an elongated fluid collection within the deep subcutaneous tissues overlying the paraspinal muscles.

The patient’s anesthesia record indicated the single-orifice epidural catheter had been inserted without difficulty for labor analgesia. At 4 days postpartum, the catheter was not available for examination. Over the 26-h labor, at least 435 mL of bupivacaine–fentanyl was infused into the epidural space and the subcutaneous tissue. When the patient eventually underwent cesarean delivery, 25 mL of 2% lidocaine with epinephrine given via the epidural catheter resulted in satisfactory anesthesia, thus confirming the appropriate position of the catheter tip. We then concluded that the subcutaneous infiltration was likely due to a breach in the epidural catheter. A follow-up MRI 2 wk later showed that some residual fluid still remained (Fig. 2).

View larger version (149K): [in this window] [in a new window]   Figure 2. Follow-up 1 mo later. There was a significant reduction in the fluid collection.

Intrathecal-cutaneous fistulae secondary to epidural or spinal needles are rare in the obstetric population, but have been reported (1,2). Fluid collections within the lumbar tissues have also been documented, but these were inflammatory reactions secondary to epidural catheter remnants (3). We were unable to locate previous reports of local anesthetic infused directly into the subcutaneous tissue, and were surprised at the capacity of the tissue to accumulate fluid and the time taken for it to be reabsorbed.

This case illustrates the importance of imaging to the differential diagnosis of complications after epidural anesthesia and their correct management, and to the provision of appropriate information for patients.

REFERENCES

1. Chan BO, Paech MJ. Persistent cerebrospinal fluid leak: a complication of the combined spinalepidural technique. Anesth Analg 2004;98:828–30.[Abstract/Free Full Text]
2. Howes J, Lenz R. Cerebrospinal fluid cutaneous fistula. An unusual complication of epidural anaesthesia. Anaesthesia 1994;49:221–2.[Web of Science][Medline]
3. Demiraran Y, Yucel I, Erdogmus B. Subcutaneous effusion resulting from an epidural catheter fragment. Br J Anaesth 2006;96:508–9.[Abstract/Free Full Text]

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