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Cerebrospinal Fluid Leak After Disconnection of an Intrathecal Catheter Adapter Placed After Inadvertent Dural Puncture
Abstract Number: FCC-353
Abstract Type: Case Report Case Series
Introduction: There remains controversy regarding the efficacy of post-delivery intrathecal (IT) catheter retainment to reduce post-dural puncture headache (PDPH) risk. Furthermore, there are inherent risks of sustaining an IT catheter. We present a case of a complication of cerebrospinal fluid (CSF) leak resulting from a disconnection of the adapter from an IT catheter that was used for continuous spinal labor analgesia and maintained post-delivery to reduce PDPH risk.
Case: A 25 year-old gravida 1 para 0 at 38 weeks 3 days was admitted for induction of labor due to intrauterine growth restriction and non-reassuring fetal heart tracing. Pertinent medical history included a history of viral meningitis complicated by seizure three years prior. She was 149 cm tall, 52 kg in weight, and a physical exam and laboratory analyses were within normal limits.
Upon labor epidural request, an L3/L4 epidural was attempted (Arrow 17G Tuohy/Arrow 19G FlexTip Plus catheter) that resulted in an inadvertent dural puncture (IDP). An IT catheter was placed for labor analgesia, which was successfully accomplished through the bolus and continuous infusion of bupivacaine 0.25% isobaric without patient-controlled functionality. The neonate was delivered by normal spontaneous vaginal delivery 11 hours later. After delivery, the anesthesia service discontinued the infusion and left the IT catheter in place, capped off, to reduce PDPH risk. No knot was tied in the catheter.
Two hours post-partum, the patient complained of mild headache. Five hours post-partum, the patient complained of wet bed sheets. The nursing staff found the IT catheter leaking liquid from it. On inspection by the anesthesia service, the catheter tip was open to air and the Arrow SnapLock catheter syringe adapter could not be found. The catheter was removed. It could not be determined when the adapter had separated from the catheter. No attempt to quantify or analyze the liquid was made, but it was assumed to be CSF. The patient complained of postural headache, but exhibited no other concerning neurologic signs. No head imaging or neurology consultation was obtained. A diagnosis of PDPH was made and, after initially declining, she underwent uncomplicated epidural blood patch 24 h later with resolution of her headache.
Discussion: A recent meta-analysis of 13 studies (2 prospective, 11 retrospective) by Deng et al. showed an association of IT catheters with a reduced rate of PDPH compared to epidural catheters. Importantly, however, the two prospective studies included in the analysis did not show a significant difference. This case highlights the risks of leaving an IT catheter in place to prevent PDPH. Providers should maintain high level of caution and vigilance if using this controversial technique to reduce PDPH risk.
Cohen S et al. Reg Anesth Pain Med. 2005; 30(6):591.
Deng et al. PLoS One. 2017; 12(7):e0180504.