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A Case Series of Unusual Inadvertent Intrathecal Catheters: "You got to know when to hold 'em, know when to fold 'em"
Abstract Number: 208
Abstract Type: Case Report/Case Series
While an intathecal catheter is not a common choice for analgesia in obstetric patients, its use is often the result of inadvertent intrathecal insertion of epidural catheters. We report two interesting case management dilemmas both applicable to obstetric anesthesia: a case of an intrathecally migrated epidural catheter complicated by a prolonged coagulopathy; and the complication of a broken intrathecal catheter during removal. A literature review of this topic will document how physicians have dealt with these complications and help to guide their management.
First we present a healthy 18 year old term parturient who presented in labor. An epidural was placed at the L3-L4 interspinous space. After appropriate testing of the catheter, EPCA was initiated. A C/S was needed 18 hours later due to failure to progress. However, upon testing the catheter prior to surgery, CSF was freely aspirated from the catheter. She underwent a C/S with 40mg lidocaine administered via the intrathecal catheter. The C/S was complicated by uterine atony, acute renal failure & thrombotic thrombocytopenic purpura post-operatively. She required multiple transfusions including red blood cells, platelets, fresh frozen plasma and cryoprecipitate for post-partum hemorrhage. Her platelet count fluctuated between 34K & 50K despite platelet transfusions during the first 5 postoperative days. Concern for risk of intrathecal hematoma and infection after 5 days with an indwelling intrathecal catheter prompted catheter removal after transfusion of two pooled units of platelets to transiently raise her platelet count to 69K. There is almost no data in the literature on how to manage indwelling spinal catheters in a parturient that suddenly develops a coagulopathy. We examine case reports on indwelling epidural catheters and non-obstetric patients for reference. Overall, one must weigh the risks of intrathecal bleeding, hematoma, and infection against the risk of platelet transfusion to determine what platelet count is appropriate for intrathecal catheter removal in the presence of a prolonged thrombocytopenia.
The second case is a 77 year old female who underwent a transvaginal hysterectomy under continuous spinal anesthesia (with an intrathecally placed epidural catheter) after accidental dural puncture with a 17 gauge Tuohy needle. Upon removal, it was noted that approximately 4-6 cm of the distal end of the catheter was missing and left inside the patient. After consulting with a neurosurgeon and the patient, a conservative approach was taken because surgery would likely result in greater morbidity for the patient in the absence of neurologic findings. She was followed for 6 weeks postoperatively without sequelae. Management of retained intrathecal catheters depends on the presence of neurological symptoms, size of the sheared fragment, infection risk, anticoagulation status, patient age, and surgical risk.