intrathecal analgesia after inadvertant dural puncture

Started by helwise, February 08, 2005, 03:45:04 PM

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helwise

I performed 2 inadvertant dural punctures at 3cm on an elderly lady (heavy smoker)  in separate spaces, following a laparotomy, whilst still intubated.The tap was discovered on both occasions by negative aspiration by a 2ml syringe, no CSF came through the Touhy needle. After the second, I decided to administer intrathecal diamorhpine 0.25mg and plain marcaine 2.5 mls before I withdrew the catheter, for postoperative analgesia. 3 minutes later she became profoundly bradycardic, hypotensive and had a repsiratory arrest. Atropine 600mcg and Naloxone 300mcg was adinistered IV, after which her heart rate, blood pressure and respiratory rate recovered. She awakened sufficiently to start going for her ETT and so I extubated her and sent her to HDU for careful post-op monitoring. Her analgesia was good immediately postoperatively.
Have many people administetred intrathecal analgesia in such patients after inadvertant dural punctures? I know it is done frequently in obstetrics, but have little knowledge of this in the elderly. If anyone has done it, any recipes for a more successful outcome?!

Sandy Hancock

Several points could be made.

First, neuraxial anaesthesia should ideally be performed in awake patients, especially if done above L2, as I presume an epidural following a laparotomy would be.

Secondly, if you had two failures, it might have been a good idea to give up. Elderly patients often have very low analgesic requirements after abdominal surgery, which is possibly why so many epidurals look so good ;) They frequently do just fine with paracetamol and a little subcutaneous morphine.

Thirdly, that was a really big dose of bupivacaine if the aim was only analgesia (I'm guessing you used 0.5% which makes for 12.5mg). I would use a fifth of that, so I'm not surprised she wobbled a bit.

I can't comment on the dose of diamorphine, as we do not use it in Australia. Perhaps it was a bit much too?

preeti

three days prior to reading ur post,i had similar experience.had dural puncture with epidural catheter.she was elderly female for orif.i used it for intrathecal supplementation of 10mg bupivacain already given in subarachnoid space as original plan was a CSE.intraop i gave two top-ups of 5mg bupivacain each and post-op i gave 15microgram fentanyl for analgesia. there was no untoward effect and the patient is quite comfortable till date,so i suppose there is no harm in giving opiods intrathecally but dose has to b decided meticulously.