Case report a thin patient underwent epidural catheter insertion

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Case report a thin patient underwent epidural
catheter insertion

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Basic data

• ??X, chart N.O.- 23432517
• A 38-year-old woman (weight, 44 kg height, 160
  cm) with hepatocellular carcinoma (7.6cm in
  diameter )
• presented to hospital for scheduled right liver
  lobectomy

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Medical history

• hepatitis B virus infection, no other systemic
  disease
• PE no remarkable finding
• Lab
• Hb 12.4, PLT 208000
• PT 12.3, APTT 37.3, INR1.1

4
1030

• Before induction of general anesthesia, epidural
  catheter insertion was planned for postoperative
  pain control.
• placed her in the lateral position, disinfect
  skin, use a 10 ml syringe with 22-gauge needle
  from paramedian approach (1.5 cm lateral and 1 cm
  caudal to the interspace of T10/11) to infiltrate
  2 lidocaine deep and superficially about 2 ml
  and 1 ml respectively

5
1040

• On the first attempt, an accidental dura puncture
  occurred, but the patient reported no shooting
  pain, pareshesia, headache or other neurological
  symptoms. The procedure hold 2 min.
• On the second attempt, epidural catheter
  placement was smooth, but nausea, and bilateral
  leg numbness and weakness were complained

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1050

• Remove the catheter, and put her in the
  Trendelenburg position.
• SpO2 was 100, I st BP 90/45 mmHg, after 4 mg
  ephedrine, BP 103/60 mmHg, then nausea improved.
• NE decreased cold sensation below the level of
  T10, bilateral lower extremity motor weakness
  (muscle power 1/5)

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After 1100

• We consulted neurologist and arranged urgent
  magnetic resonance imaging (MRI) of the patients
  thoracic spine. MRI revealed no finding!
• About 2 hours after dura puncture, lower
  extremity musle power gradually returned to 5/5,
  and sensation to pinprick and light touch was
  intact.

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So

• the operation was postponed to the next week, and
  she discharged on the next day without any
  neurological sequela.

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Discussion

• Spinal cord damage should be ruled out first!
• The incidence (lt0.02) of permanent paraplegia
  resulted from spinal cord damage related to
  thoracic epidural placement is vary rare, we
  should not be negligent.
• Giebler RM, Scherer RU, Peters J. Incidence of
  neurologic complications related to thoracic
  epidural catheterization. Anesthesiology
  1997865563

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Discussion

• Even the patient did not tell any shooting pain
  or paresthesia while dura puncture, spinal cord
  damage should also be considered.
• Ban C. H. Tsui, Kevin Armstrong. Can direct
  spinal cord injury occur without paresthesia? A
  report of delayed spinal cord injury after
  epidural placement in an awake patient. Anesth
  Analg 200510112124

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Discussion

• Immediate Magnetic resonance imaging is
  recommended to find potentially reversible causes
  of neural damage.
• John Butterworth, Annette Douglas-Akinwande.
  Lower extremity paralysis after thoracotomy or
  thoracic epidural Image first, ask questions
  later. Anesth Analg 20071042013

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Discussion

• Greater resolution of MRI than that of CT makes
  MRI the imaging of choice to evaluate the
  deficits of spinal cord.
• Kaiser JA, Holland BA. Imaging of the cervical
  spine. Spine 199823270112

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Discussion

• Could epidural or subarachnoid local anesthetics
  injection possible?
• nausea and hypotension were noted
• For patients with high level neuraxial block,
  Trendelenburg position should be placed to
  increase venous return, and intravenous Atropine
  or Ephedrine should be administered to treat
  bradycardia or hypotension
• Miller Miller's Anesthesia, 6 th ed

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Discussion
the distance between skin to dura is only about
2.5 cm at the level of T10 in the midline
(sagital plane)
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Discussion
a line indicates the distance between skin to
dura (2.5 cm), b line means 1.5 cm lateral to the
center of the T10/11 interspace, and c line
almost exhibits depth of the epidural space in
paramedian approach (about 2.92 cm)
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Discussion

• the mean thoracic epidural depth in paramedian
  approach was (mean SD) 5.11 0.94 cm, and the
  depth was positively correlated with the body
  weigh and body mass index but was unrelated to
  sex, age, or body height. In this study, the mean
  body weight of patients was 60.5 kg, and every
  increase of 10 kg in the body weight lengthened
  the distance by 0.39 cm
• H.-C. Lai et al. Depth of the thoracic epidural
  space in paramedian approach. Journal of Clinical
  Anesthesia (2005) 17, 339343

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Discussion

• The length of 22-G needle used for 2 lidocaine
  deep and superficial infiltration is 3.2 cm,
  therefore it was possible that inadvertent
  epidural or subarachnoid local anesthetics
  injection happened.

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Discussion

• So it may be helpful to know the distance for
  epidural catheter insertion before this
  procedure.
• Kao et al. reported that preoperative abdominal
  CT is helpful to predict the depth of thoracic
  epidural insertion in paramedian approach.

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Discussion

• The estimated insertion length (EIL) calculated
  from skin to epidural space on the transverse CT
  plane at the corresponding T10/11 interspace is
  (mean SD) 5.5 0.7, the actual insertion
  length (AIL) is (mean SD) 5.1 0.6, and both
  of EIL and AIL have significant correlations with
  body weight, BMI, and fat percentage, but not
  with height.
• Kao et al. Prediction of the distance from skin
  to epidural space for
• low thoracic epidural catheter insertion by
  computed tomography.
• British Journal of Anaesthesia 92 (2) 271-3
  (2004)

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Discussion
29.71 mm
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Conclusion

• Once paraplegia related to epidural catheter
  placement occurred, the first is to rule out
  spinal cord damage.
• The imaging of choice to detect cord deficits is
  MRI which can reveal reversible causes of neural
  damage.
• inadvertent epidural or subarachnoid local
  anesthetics injection should be considered if the
  patient is very thin.

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Conclusion

• mean thoracic epidural depth in paramedian
  approach is about 4-6 cm, and correlated with the
  body weigh and BMI.
• We can predict the depth of epidural space from
  preoperative abdominal CT (EIL). Therefore,
  advancing the needle closer to or over the EIL
  should be done with caution.
• Epidural analgesia is good for postoperative pain
  control, but it may lead to severe complications,
  so we should be vigilant.

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Thanks for your attention !!!