Indian Journal of Anaesthesia  
About us | Editorial board | Search | Ahead of print | Current Issue | Past Issues | Instructions
Home | Login  | Users Online: 17  Print this pageEmail this pageSmall font sizeDefault font sizeIncrease font size    




 
 Table of Contents    
LETTER TO EDITOR
Year : 2011  |  Volume : 55  |  Issue : 6  |  Page : 629-630  

A rare complication of epidural anaesthesia a case report with brief review of literature


Department of Anaesthesiology, Moolchand Medcity, New Delhi, India

Date of Web Publication5-Dec-2011

Correspondence Address:
Parvez S Lala
F 171, Lajpat Nagar, 1 New Delhi
India
Login to access the Email id


DOI: 10.4103/0019-5049.90631

PMID: 22223915

Get Permissions


How to cite this article:
Lala PS, Langar V, Rai A, Singh R. A rare complication of epidural anaesthesia a case report with brief review of literature. Indian J Anaesth 2011;55:629-30

How to cite this URL:
Lala PS, Langar V, Rai A, Singh R. A rare complication of epidural anaesthesia a case report with brief review of literature. Indian J Anaesth [serial online] 2011 [cited 2014 Oct 24];55:629-30. Available from: http://www.ijaweb.org/text.asp?2011/55/6/629/90631

Sir,

A 29-year-old, G1-P0, woman presented to our delivery suite at 39 weeks of gestation, in early labour. 70 minutes later, at 4 to 5 cm cervical dilatation, she requested an epidural labour analgesia.

Her medical and obstetric history was unremarkable, and she was not taking any medication. The epidural space was identified in the L3-4 interspace at a depth of 7 cm using the loss of resistance to saline technique, with an 18-gauge Tuohy needle and the catheter was easily inserted with the patient in left lateral position. The catheter was threaded to the 15 cm mark, the needle was removed and the catheter was left with 11 cm mark at the skin. This left 4 cm of catheter in the epidural space. Following a test dose of 3 ml of lignocaine 2% with 1:200000 epinephrine, the catheter was taped in place. 10 ml of bupivacaine 0.125% solution with 50 μg fentanyl was administered after no signs of intravascular or subarachnoid cannulation. Then, the catheter was connected to bupivacaine 0.125% and fentanyl 2 μg/ml infusion at a rate of 7 ml/hr. The patient was attached to the automatic blood pressure measurement machine, foetal heart monitor and an intravenous (iv) fluid of Ringer's lactate was run. Patient was comfortable and stable all through her labour which lasted around 4 hours.

After vaginal delivery, the catheter could not be removed. Repeated attempts to remove the catheter continued to be unsuccessful; however, after four attempts, we pulled out the catheter by steady increase in the traction force. Fortunately, the epidural catheter was removed intact without shearing. The patient experienced no paraesthesia or other symptoms during the procedure. However, inspection of the catheter revealed a tight knot about 1 cm from the tip and slight catheter stretching proximal to the knot was also observed [Figure 1] (epidural catheter knotting). However, the subsequent postnatal period of the patient remained uneventful.
Figure 1: Epidural catheter knotting

Click here to view


Epidural analgesia still is the most effective way of labour pain relief but unfortunately this luxury comes at a price of some complications. Though serious complications to epidural anaesthesia or analgesia are uncommon, rarely knotting of lumbar and caudal epidural catheters has been reported, [1],[2],[3] which has an estimated incidence of 0.0015%.

Several sources have suggested that advancing the catheter beyond a certain distance into the epidural space increases the incidence of epidural knotting, [2] but still there is no consensus about the optimal length of catheter insertion. Conceptually, an epidural catheter may tend to curl or coil if threaded more than 4 or 5 cm. However, development of a knot in a catheter that was inserted <3 cm has also been reported. [4] Thus, signifying the role of other factors, like the type of catheter and the level of catheter placement. Depending on catheter type and level of insertion, insertion lengths from 2 to 8 cm have been proposed. [1],[3] Since the catheter placed in our patient was inserted upto 15 cm and then withdrawn and fixed at 11 cm mark in the lumbar region; this must have probably allowed the catheter to turn 180° and form a knot.

The management proposed for an irretrievable epidural catheter includes change of the patient's position, [5] steady stretch or pull-out possibly under administration of general anaesthesia, [2] radiological investigation using contrast medium or guidewire and surgical intervention.

Some studies found patient position to be a factor for ease of catheter removal. They reported that less force is required to remove a catheter in the lateral position, with a gentle and steady traction placed on the catheter at the skin. Steady traction allows the catheter and the knot to decrease in diameter and thus facilitating its passage through the ligaments.

Fortunately, in our case, the catheter could be pulled out by using a steady force without the patient experiencing any neurological symptoms. Although pulling may result in tearing the catheter, steady and gentle stretch is frequently successful by making a possible knot smaller. It is firmly stressed that neurological functions should be carefully observed during the procedure. If signs like paraesthesia, radicular-type pain or any other signs of possible spinal root damage appear, further attempts at withdrawing should be abandoned. It is mandatory to delay all attempts to retrieve the catheter until all effects of the administered local anaesthetic have worn off.

Fortunately, following the guideline of slow, steady and gentle traction in the absence of paraesthesia, we were successful in removing the tip of knotted epidural catheter intact.

 
   References Top

1.Browne RA, Politi VL. Knotting of an epidural catheter: A case report. Can J Anaesth Soc J 1979:26:142-4.  Back to cited text no. 1
    
2.Renehan EM, Peterson RA, Penning JP, Rosaeg OP, Chow D. Visualization of a looped and knotted epidural catheter with a guidewire. Can J Anaesth 2000:47:329-33.  Back to cited text no. 2
    
3.Gozal D, Gozal Y, Beilin B. Removal of knotted epidural catheters. Case reports. Reg Anesth 1996:21:71-3.  Back to cited text no. 3
    
4.Fibuch EE, McNitt JD, Cussen T. Knotting of the TheracathTM after an uneventful epidural insertion for cesarean delivery (Letter). Anesthesiology 1990:73:1293.  Back to cited text no. 4
    
5.Morris GN, Warren BB, Hanson EW. Influence of patient position on withdrawal forces during removal of lumbar extradural catheters. Anesthesiology 1997;86:778-4.  Back to cited text no. 5
    


    Figures

  [Figure 1]


This article has been cited by
1 Major complications of epidural anesthesia: a prospective study of 5083 cases at a single hospital
X.-H. KANG,F.-P. BAO,X.-X. XIONG,M. LI,T.-T. JIN,J. SHAO,S.-M. ZHU
Acta Anaesthesiologica Scandinavica. 2014; : n/a
[Pubmed]
2 Removing a trapped epidural catheter: Concerns
Garg, R. and Gupta, R.C.
Indian Journal of Anaesthesia. 2012; 56(2): 211-212
[Pubmed]
3 Re: A rare complication of epidural anaesthesia. A case report with brief review of literature
Hobaika, A.B.
Indian Journal of Anaesthesia. 2012; 56(2): 205
[Pubmed]



 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
    References
    Article Figures

 Article Access Statistics
    Viewed1043    
    Printed48    
    Emailed0    
    PDF Downloaded283    
    Comments [Add]    
    Cited by others 3    

Recommend this journal