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Migration of epidural catheters and emergency cesarean section: A case for test dose!
Abstract Number: SU-93
Abstract Type: Case Report/Case Series
Case report: A 27 y/o G9P6 morbidly obese female requested epidural for trial of labor, after cesarean x1. Patient had 5 prior functioning lumbar uneventful epidurals for vaginal deliveries. Multi-orifice epidural catheter was placed when patient was 2cm dilation without incidence. Analgesia was maintained with 0.0625% bupivacaine + 3mcg/mL fentanyl at a rate of 12mL/hr. Ten hours later the infusion rate was reduced to 5mL/hr to allow rest before restarting augmentation 12 hours later. Nine hours later, at 7cm dilation, an emergency section was called for FHR in 70s. She had adequate BL T10 analgesia. Patient moved herself to OR table from bed. After a negative aspiration, epidural block was augmented with 5+10 mL 3% 2-chloroprocaine (2CP) given over 3 minutes. After 5 minutes block level tested with cold was assessed to be at T4. Two minutes later patient started to complain of dyspnea and difficulty speaking with weak handgrip. Block level was reassessed above C3, necessitating mask ventilation. General anesthesia was induced for apnea. Patient remained hemodynamically stable through RSI. After intubation, patient became hypotensive, requiring pressors to keep SBP above 80 mmHg. Aspiration of the epidural catheter at this time was positive for over 15 ml of free flowing CSF. Surgery, delivery, and GA were uneventful. Neonatal APGAR scores were 6 and 8 at 1 and 5 minutes. Contrary to our concern for a prolonged intubation, patient had spontaneous ventilation 40 minutes after 2CP. Her minute ventilation was 11.6L/min. Patient was extubated. Catheter aspiration now was negative, but considered IT and left in site for 24 hrs, to reduce incidence of PDPH. Forth aspiration before removal was positive for CSF, confirmed with glucose of 68 on ABG run with the sample.
Conclusions: Migration of epidural catheters is uncommon but well documented. As patient was comfortable even with 5 mL/hr infusion rate, we propose this catheter was initially epidural and migrated to subdural space. Catheter may have later migrated into intrathecal space, after 15 mL of 2-CP was given. 3% 2-CP injected intrathecally should act much faster than 5 minutes. An intermediate timing with out of proportion high sensory level, possible intercostal muscle weakness, and severe hypotension suggest subdural migration initially. We believe that sudden expansion of subdural space led to arachnoid rupture allowing us to aspirate free-flowing CSF intermittently. Leak into subdural space alternating with reabsorption of fluid from space may have resulted in this phenomenon. We think that limiting test dose to 3 mL prior to next dose 5 minutes later would have helped in this particular scenario.
Reference: Agarwal,D., et al. Subdural block and the anaesthetist. Anaesthesia and intensive care. 2010. Vol 38. No. 1.