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Percutaneous Cerebrospinal Fluid Leakage after Continuous Intrathecal Catheter
Abstract Number: SUN-45
Abstract Type: Case Report/Case Series
Recent literature supports the use of continuous intrathecal catheters after unintentional dural puncture in obstetric patients. Keeping intrathecal catheters in place for 24hours after unintentional puncture may reduce the risk of postdural puncture headache in patients and decrease the need for invasive management with epidural blood patch. Here we report an unusual complication of a continuous intrathecal catheter in the obstetric patient.
A 37yo G1P0 at 34w6d gestational age presented with premature rupture of membranes and underwent augmentation of labor with oxytocin infusion for labor. She requested neuraxial anesthesia and after 4 unsuccessful attempts at epidural catheter placement had an unintentional postdural puncture with a 17g touhy needle. A 19g multiport closed tip catheter was placed easily intrathecally and maintained throughout labor with adequate analgesia without significant motor block. The catheter was removed immediately after delivery. She was discharged without reports of headache. She then returned to the hospital on postpartum day 4 with primary complaint of clear leakage at insertion site of intrathecal catheter with approximately one drop forming every 45 seconds. Although the fluid was never confirmed to be CSF, its appearance was highly suggestive it was. She reported only mild frontal non-postural headache without neurological symptoms. A suture was placed to control the percutaneous leak and no blood patch was performed.
After unintentional post dural puncture, the rate of PDPH has been reported to be as high as 75% with its pathophysiology primarily from continued CSF leakage and resultant meningeal traction. This patient’s presentation of delayed and continued CSF leakage from the puncture site is consistent with that of a rare complication of intrathecal catheters, a cerebrospinal fluid-cutaneous fistula. These case reports are primarily reported in non-obstetric literature such as pediatric neuraxial anesthesia and post laminectomy surgery. Although no set guidelines exist on the management of these fistulas, case reports describe successful treatment with conservative management with primary closure of the cutaneous portion of the fistula to epidural blood patchs.
-Ayad, S., Demian, Y., Narouze, S. N., & Tetzlaff, J. E. (2003). Subarachnoid Catheter Placement After Wet Tap for Analgesia in Labor. Regional Anesthesia and Pain Medicine, 28(6), 512-515.
-Lenart, M. J., & Carness, J. M. (2016). Cerebrospinal Fluid-Cutaneous Fistula After Continuous Spinal Catheter in an Obstetric Patient. A & A Case Reports, 7(5), 103-107.
-Chestnut, D. H. (Ed.). (2004). Obstetric anesthesia: principles and practice. St. Louis: Mosby.
-Franklin, A. D., & Hays, S. R. (2013). Successful management of a thoracic cerebrospinal fluid cutaneous fistula in a two year old child using a thoracic epidural blood patch. Journal of Clinical Anesthesia, 25(4), 331-334