Anesth Analg 2007;104:735-737
© 2007 International Anesthesia Research Society
doi: 10.1213/01.ane.0000255654.01482.74
ANALGESIA
Unrecognized Contralateral Intrapleural Catheter: Bilateral Blockade May Obscure Detection of Failed Epidural Catheterization
Michael A. Cordone, MD, MPH*,
Christopher L. Wu, MD*,
Aimee L. Maceda, MD , and
Jeffrey M. Richman, MD*
From the Departments of *Anesthesiology and Critical Care Medicine and Radiology, The Johns Hopkins University, School of Medicine; Baltimore, Maryland.
Address correspondence and reprint requests to Jeffrey M. Richman, MD, Department of Anesthesiology and Critical Care, The Johns Hopkins Hospital, 600 N. Wolfe St., Carnegie 280, Baltimore, MD 21287. Address e-mail to jrichma1{at}jhmi.edu.
Abstract
Thoracic epidural analgesia has been widely used to reduce both postoperative and posttraumatic pain. We describe a case of inadvertent right-sided interpleural catheter placement and pneumothorax during attempted epidural catheter placement for left-sided rib fractures that went unrecognized because of bilateral blockade and adequate analgesia.
Thoracic epidural analgesia has been widely employed to reduce both postoperative and posttraumatic pain (1–3). However, complications, including interpleural catheter placement and pneumothorax, have been reported during both midline and paramedian approaches (4–8). We present a unique case of inadvertent pleural catheter placement and pneumothorax of the contralateral lung that went initially unrecognized in part due to bilateral blockade.
CASE REPORT
A 68-year-old woman with a medical history of morbid obesity (135 kg, 160 cm height) and obstructive sleep apnea requiring continuous positive airway pressure at night was injured in a motor vehicle accident. Computerized tomography (CT) demonstrated left-sided rib fractures from T3–8 and a compression fracture of T5. One day after admission, a repeat CT scan showed a large left pleural effusion with displacement of the mediastinum. Two left-sided chest tubes were ultimately placed, and the patient was transferred to the surgical intensive care unit where she continued to have respiratory distress and required bilevel positive airway pressure. Two days after the initial injury, the acute pain service was consulted for thoracic epidural catheter placement because of inadequate analgesia with IV patient-controlled analgesia and worsening respiratory status.
After ascertaining normal coagulation status, International normalized ratio 1.0 and partial thromboplastin time ratio 0.9, the patient was placed in the right lateral decubitus position with several unsuccessful attempts to advance a 17-gauge Tuohy using a midline approach at both the T7–8 and T6–7 levels. No blood, air, or cerebrospinal fluid was detected. The attending anesthesiologist obtained loss of resistance with easy catheter advancement at T6–7 via a left paramedian approach 2.5 cm lateral to midline. However, accidental displacement of the catheter occurred during needle removal. A left paramedian approach was repeated at T6–7, 2.5 cm lateral of midline with loss of resistance at 13 cm, and uneventful catheter advancement. The catheter was secured 20 cm at the skin. The test dose was negative for intravascular or intrathecal injection. A bolus of 7 mL of 0.125% bupivacaine resulted in a decreased response to cold on the left side from T3–11 and a reduction in visual analog scale (VAS) (0–10 cm) from 10 to 7 cm. Only the left side, where fractures were present, was tested. At 17:00, approximately 10 min after the epidural was secured, patient-controlled epidural analgesia was instituted using 0.125% bupivacaine with 5 µg/mL fentanyl (basal rate 5 mL/h, bolus 2 mL, lockout 10 min). The patient’s analgesia remained inadequate, though improved significantly from baseline, through the night (VAS ranging from 5 to 8 cm), requiring intermittent boluses and increases in the basal rate. A sensory level was not documented during these interventions. At 04:00 the following morning the resident withdrew the catheter back 2 cm and rebolused with 5 mL of 0.125% bupivacaine, resulting in complete analgesia (VAS 0). During acute pain service rounds at 08:00, the patient’s analgesia remained adequate (VAS 3 cm) with a basal rate of 9 mL/h. Despite acceptable analgesia, the patient was still in respiratory distress on bilevel positive airway pressure, and required intubation. A CT scan performed that afternoon revealed a new right pneumothorax (contralateral to both the rib fractures and needle insertion sites), with no mention of a catheter. A right-sided chest tube was placed. Because of hypotension, the epidural was used intermittently over the next 2 days until reinstitution after a negative test dose. A bolus of 0.25% bupivacaine resulted in bilateral sensory blockade from T2–10, as determined by decreased response to cold. The patient was managed with the epidural (basal rate of 6 mL/h of 0.125% bupivacaine with 5 µg/mL fentanyl) in addition to an IV patient-controlled analgesia (bolus 20 µg of fentanyl, lockout 10 min), resulting in excellent analgesia (VAS 1 cm) with one to three demand doses per hour. A decrease in hemoglobin the following day prompted a helical CT scan, which noted a catheter entering the right posterior chest and residing in the right pleural space. Re-review of the initial CT scan after epidural placement identified the catheter in the right pleural space, with an insertion near T6 and the catheter tip found near the apex of the lung at T1 (Fig. 1). Because of excellent analgesia with the interpleural catheter, the infusion was continued for two more days until failure of adequate analgesia was noted and the catheter was removed without complication. The patient was confined to bed rest from the time she received the catheter to the time it was removed due to her size and injuries. The patient received a tracheostomy on day 12 and a left-sided pulmonary decortication on day 19. The patient was converted to a cuffless fenestrated tracheostomy on day 32 and was transferred to a rehabilitation facility.
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Figure 1. Thoracic computed tomography scan using lung windows. A new pneumothorax is seen on the right as in an interpleural catheter. Also visualized is chest tube on left, pneumothorax on left, subcutaneous emphysema on left, and shifting of mediastinum to the right.
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DISCUSSION
We describe a case of inadvertent interpleural catheter placement during attempted epidural catheter placement to the contralateral lung that went unrecognized due to bilateral blockade. Although several cases of interpleural insertion of epidural catheters have been reported, the incidence appears to be low (5–7). We were unable to identify any case reports of contralateral (with paramedian approach) pneumothorax and interpleural catheter placement with satisfactory bilateral blockade after attempted epidural catheterization. Although migration of catheters into the interpleural space has been reported (7), the pneumothorax on the right side, along with our review of the CT, confirms that the needle was placed directly into the interpleural space.
Accidental interpleural catheters have recently been reported to provide satisfactory analgesia when dosed with a larger than usual infusion of local anesthetic (9). Although there are several modalities to control thoracic pain, thoracic epidural analgesia is superior to interpleural catheters in providing analgesia (10). In the setting of a recognized inadvertent interpleural catheter placement, authors have recommended removal of the catheter with subsequent replacement into the epidural space (5,6). Conversely, a recent case report suggests that if replacement of the catheter is not feasible, then administration of local anesthetic through the interpleural catheter could be a potential alternative (9).
A distinctive characteristic of this case was the bilateral block achieved by the interpleural catheter. Paravertebral spread of local anesthetic has been demonstrated to result in bilateral spread (11) both epidurally (12) and via "subserous fascia" (13,14); anterior to the vertebral bodies. This was not a paravertebral catheter; however, the catheter was lateral to the transverse process and interposed between lung and ribs throughout its course, as confirmed by CT.
It is likely that the inability to identify superficial landmarks in our morbidly obese patient and an exaggerated angle of the Tuohy needle increased the risk of catheter misplacement (5,7). In addition, both epidural and interpleural insertion of a Tuohy needle will result in a loss of resistance (5–7), making inadvertent interpleural placement difficult to identify. The pneumothorax on the right side provided evidence that the Tuohy needle breached the pleura during one of the attempts at epidural catheterization. Evidence of bilateral neural blockade generally indicates epidural placement. Although careful examination of a chest radiograph or CT scan should allow detection of catheter misplacement, there was no suspicion of interpleural placement because of the bilateral analgesia. Ultimately, this was noted several days after attempted epidural placement. In summary, we present a case of accidental interpleural catheter placement and pneumothorax that went undetected because of bilateral blockade.
Footnotes
Accepted for publication November 29, 2006.
Supported by the Department of Anesthesiology and Critical Care Medicine of The Johns Hopkins University.
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