CSE – Iatrogenic technical difficulties

Started by jafo1964, April 15, 2011, 02:00:26 PM

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A 72 year old hypertensive & COPD patient with a trochanteric fracture was worked up for DHS
HT was controlled with Atenolol 50 mg OD
He had a smoking history of 50 pack years and had bad lungs at admission. The chest physician started him on Nebulized beta2 agonists, steroids and ipratropium.  As no improvement was seen he added IV Methylprednisolone 125 mg tds.
On day3 at assessment,  lungs still had bilateral wheeze and scattered crepitations and his ECHO was normal but for the concentric LVH. ECG was within normal limits and CXR showed tubular heart with hyperinflated lung fields.
Since conversion to GA if necessary would be risky, a CSE ( 2 needle, 2 interspace sequential technique) was planned so that post-op analgesia could be provided with an elastomeric pump infusion. LMWH dose was withdrawn 24 hours before needle placement.
After all the initial set up in OT as per scientific protocol, with the patient sitting Epidural attempted at L34 ISS with 16G Tuohy needle using LORT air technique. Inadvertent dural puncture ensued and the needle was withdrawn. Repeat epidural was done in T12L1 ISS, space identified and the catheter was passed caudad upto 4 cms in space to tip it probably at L23 level. When the catheter was aspirated CSF was noted. Uncertain about catheter position, epidural test dose was abandoned but the catheter was secured in place.
As per original plan, SAB was done in L34 ISS with 25G Quincke needle without experiencing any technical difficulty. 3 ml of 0.5% hyperbaric bupivacaine was given after free flow of CSF to aspiration.
Patient during  positioning on the fracture table was pain free but patient complained of pain to incision.
Epidural catheter reaspiration showed CSF. Hence hyperbaric 5% lignocaine was injected into the catheter to try and attempt a continuous spinal. 0.5 ml produced no improvement in analgesia or no decrease in BP. Every 5 mins a dose of 0.5ml ( total 3 doses)  was repeated but did not produce any effect.
Then 2% lignocaine with 1 in 200000 adrenaline was injected into the epidural catheter 2 ml / every 10 mins. After injection of about 6 ml, analgesia was complete and adequate and from then on surgery proceeded uneventfully. Intraoperatively 2 other epidural  top ups of 4 ml each were used without any untoward effect on block characteristics or hemodynamics.
1.   How better could this case have been managed
2.   What is the management protocol  followed by majority in event of dural tap and / or CSF in the catheter
3.   Why did the spinal become patchy.  Although the most likely cause is placement of drug in the wrong space ( partially atleast because there was a block) Just wondering that if the lingo injected in L34 could have  spilled out of the subarachnoid space along with CSF from the dural puncture in the L23 space. Is that a possibility. Has anybody experienced it
4.   CSF in the catheter – was it from the catheter being in the subarachnoid space or the CSF leaked out of the dural puncture site and lying in epidural space. How to differentiate between the two scenarios.


BAck again for you to reply to your question.
First, I may probably plan a continuous spinal and do a deliberate dura puncture.
If Dura Puncture, I like to accept it and push my cath inside. The result is sure, and fast, dose minimal and safe. PDPH, I have not yet faced after A dura Puncture, with a cath inside. It blocks the hole partially and little protein from CSF collects there and forms coagulum, blocking  the puncture site.
I have done this often when I am in a situation like you mentioned, specially so if I am in a smaller hospital, where all facilities may not be there.
But I usually knot up my catheter, so that some one does not take it as an Epidural cath and inject something else by error.
I remove the cath on 2nd day.
In your case, we have to also think in terms of Analgesia. I do not like to inject any thing in this cath with a fear of sepsis. May be we can think of something else, like on shot Buprenorphi giving good analgesia for almost 24 hrs. Later plain IV Paracetamol can help.
May not be very agreeble at a few levels, but still works out better than ending up in a GA.