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LETTER TO EDITOR
Year : 2015  |  Volume : 59  |  Issue : 2  |  Page : 133-135  

No rent is small for migration of epidural catheter into sub-arachnoid space


Department of Anaesthesia, Institute of Liver and Biliary Sciences, Vasant Kunj, New Delhi, India

Date of Web Publication13-Feb-2015

Correspondence Address:
Dr. Manish Tandon
Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi - 110 070
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5049.151384

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How to cite this article:
Tandon M, Pandey CK. No rent is small for migration of epidural catheter into sub-arachnoid space. Indian J Anaesth 2015;59:133-5

How to cite this URL:
Tandon M, Pandey CK. No rent is small for migration of epidural catheter into sub-arachnoid space. Indian J Anaesth [serial online] 2015 [cited 2019 Oct 15];59:133-5. Available from: http://www.ijaweb.org/text.asp?2015/59/2/133/151384

Sir,

Epidural analgesia forms the mainstay of pain relief in abdominal surgeries. [1],[2] Epidural needle placement and catheter insertion are preferably performed under local anaesthesia, before induction of general anaesthesia. [3] Dural puncture by the epidural needle is a known complication, and the reported incidence of accidental dural puncture varies from 0.4% to as high as 6%. [4] Dural puncture precludes the catheter placement in the same inter-vertebral space because rent created in the dura mater may allow intra-thecal migration of the epidural catheter. We report a case of inadvertent intra-thecal migration of the epidural catheter through a dural puncture by a 26 gauge needle.

A 38-year-old male patient, height 167 cm and weight 63 kg. was posted for hepato-jejunostomy for the benign stricture of the common bile duct. After a written informed consent, patient was taken up for the surgery. As part of perioperative anaesthesia care, epidural catheter placement was planned in the sitting position. With all sterile precautions, inter-vertebral space between 8 th and 9 th thoracic vertebra was marked and was punctured with a 26 gauge 1½ inch long needle, for infiltration of local anaesthesia. An aspiration check before injecting the local anaesthetic revealed that probably dura mater had been punctured, and fluid, possibly cerebro-spinal fluid (CSF) was getting aspirated. A note of the depth at which dura mater was punctured was made. Because the dura mater was punctured with a 26 gauge needle, too small to be of concern, it was decided to use the same inter-vertebral space for epidural catheter placement. Epidural space was identified by the loss of resistance technique with a 16 Gauge 12 cm long Tuohy epidural needle (with catheter stabiliser). Skin to epidural space distance was 4 cm. There was no CSF leakage at the hub of the epidural needle. The epidural catheter was easily inserted through the needle but just as the catheter had crossed the mark of 14 cm at needle hub, fluid was seen flowing into the catheter. Fluid was aspirated into a syringe, and it was confirmed as CSF (temperature and sugar content of the aspirated fluid). Epidural catheter was then withdrawn and was placed in an inter-vertebral space higher up. Rest of the course of the hospital stay of the patient was uneventful.

Dural puncture by epidural catheter on its own is not possible, though arachnoid puncture by the epidural catheter has been shown in an experimental study. [5] In our patient since dura mater and the arachnoid mater were punctured with a 26 G needle, it would have created a weak point through which subsequently the epidural catheter would have travelled into the intra-thecal space. Robbins et al. had also reported a similar case where accidental intra-thecal insertion of an extradural catheter happened during combined spinal-extradural anaesthesia. [6] They used a 26 gauge Whitacre spinal needle through 16 gauge Tuohy extradural needle. Physical characteristics like height and weight can be used to predict the depth of the epidural space to guide epidural needle placement. Ravi et al. in their study had concluded that the mean depth of epidural space in patients of body mass index (BMI) <30 is 41.60 ± 5.80 mm on the basis of a formula (Depth [mm] = a + b [BMI]. where a = 17.7966 and b = 0.9777). [7] Our patient with a calculated BMI of 22.6, the predicted depth of the epidural space was 39.89 mm. Whereas skin to sub-arachnoid space depth (SSD) in Indian males is reported to be 4.81 ± 0.68 cm, [8] the formula derived for determining SSD in the Indian population, 2.71 + 0.09 × BMI, predicts SSD of 4.74 cm for our patient. [8] We located the epidural space at 4 cm depth from the skin that was well within the predicted depth for epidural space, and was short of the predicted SSD. This also supports our observation that the epidural needle was indeed in the extradural space. In our case, that the epidural catheter migrated into the sub-arachnoid space in the absence of any undue force warrants caution. We suggest that caution should be exercised even while puncturing inter-vertebral space for infiltration for local anaesthesia and in case dural puncture happens, epidural puncture should not be attempted in the same inter-vertebral space.

 
   References Top

1.
Bajaj P. Regional anaesthesia versus general anaesthesia: Is there an impact on outcome after major surgery? Indian J Anaesth 2007;51:153-4.  Back to cited text no. 1
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2.
Bajaj U, Rana SP, Kumar A, Saxena S, Chand T, Kannaujia A, et al. Role of epidural anaesthesia and analgesia in reducing postoperative morbidity and mortality during major abdominal surgery. Indian J Anaesth 2008;52:541-5.  Back to cited text no. 2
    
3.
Fischer HB. Regional anaesthesia - Before or after general anaesthesia? Anaesthesia 1998;53:727-9.  Back to cited text no. 3
[PUBMED]    
4.
Jadon A, Chakraborty S, Sinha N, Agrawal R. Intrathecal catheterization by epidural catheter: Management of accidental dural puncture and prophylaxis of PDPH. Indian J Anaesth 2009;53:30-4.  Back to cited text no. 4
[PUBMED]  Medknow Journal  
5.
Hardy PA. Can epidural catheters penetrate dura mater? An anatomical study. Anaesthesia 1986;41:1146-7.  Back to cited text no. 5
[PUBMED]    
6.
Robbins PM, Fernando R, Lim GH. Accidental intrathecal insertion of an extradural catheter during combined spinal-extradural anaesthesia for caesarean section. Br J Anaesth 1995;75:355-7.  Back to cited text no. 6
    
7.
Ravi KK, Kaul TK, Kathuria S, Gupta S, Khurana S. Distance from skin to epidural space: Correlation with body mass index (BMI). J Anaesthesiol Clin Pharmacol 2011;27:39-42.  Back to cited text no. 7
[PUBMED]  Medknow Journal  
8.
Prakash S, Mullick P, Chopra P, Kumar S, Singh R, Gogia AR. A prospective observational study of skin to subarachnoid space depth in the Indian population. Indian J Anaesth 2014;58:165-70.  Back to cited text no. 8
[PUBMED]  Medknow Journal  




 

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