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///2018 Abstract Details
2018 Abstract Details2019-08-02T15:57:01-05:00

Unintended intrathecal catheter in a laboring parturient recognized during programmed intermittent epidural bolus

Abstract Number: S5D-4
Abstract Type: Case Report/Case Series

Chrison Wong MD1 ; Matthew Simms MD, MSc, FRCPC 2; Ronald B George MD, FRCPC3

Background:

Programmed intermittent epidural bolus (PIEB) has emerged as a superior method for maintenance of epidural analgesia compared to continuous epidural infusion (CEI)1. PIEB may result in lower hourly local anesthetic requirements, a shorter second stage of labor, and greater patient satisfaction2. We describe a case of an unintended intrathecal catheter discovered when a PIEB led to dyspnea during labor and subsequent management of a post-dural puncture headache (PDPH). Patient consent was obtained to report the case details.

Case features:

The patient was a healthy 34-year-old gravida 2 para 1 at 39 weeks gestation with an uncomplicated pregnancy. An epidural catheter was placed at the L3-4 level. There was no cerebrospinal fluid flow through the Tuohy needle during placement of the catheter and catheter aspiration after insertion was negative for cerebrospinal fluid. The patient received a 10 mL loading dose of ropivacaine 0.2% with fentanyl 10 mcg/mL and three programmed boluses of 8mL of 0.1% ropivacaine with fentanyl 2 mcg/mL over the next two hours. The patient developed dyspnea and mild decrease in oxygen saturation two hours after placement of the catheter. Hemodynamics remained stable. Neurological examination revealed complete bilateral motor block in the lower extremities and a sensory block up to level T4. PIEB was discontinued and the suspected intrathecal catheter was left in place. The patient’s dyspnea resolved, and she slowly regained lower extremity motor function over the following two hours. A single manual bolus of 0.5 mL bupivacaine 0.25% was administered via the intrathecal catheter prior to delivery. The patient had an uncomplicated spontaneous vaginal delivery. The patient subsequently developed a PDPH one day after removal of the catheter. An epidural blood patch provided two days of relief. However, a second blood patch was required to completely resolve the PDPH.

Discussion:

Our institution’s practice is to use PIEB for maintenance of labor analgesia. This case illustrates the potential complication of a high sensory and motor blockade that may occur with inadvertent intrathecal catheter placement. This is unlikely a case of catheter migration. We theorize that bolus dosing of low-dose local anesthetic with PIEB compared to CEI may lead to earlier recognition of high spinal block in the setting of inadvertent placement of an intrathecal catheter.

References:

1. Anesth Analg. 2013 Jan;116(1):133-44.

2. Anesth Analg. 2016 Oct;123(4):965-71.

SOAP 2018