Epidural analgesia in a patient with an intrathecal catheter and subcutaneous pump to deliver baclofen

Baclofen is used for the treatment of spasticity. Small doses administered intrathecally achieve high cerebrospinal fluid concentrations with reduced side-effects. Pediatric anesthesiologists are often reluctant to consider epidural analgesia in children receiving baclofen via an intrathecal catheter and subcutaneous pump. This reluctance is based on concerns for damaging the intrathecal catheter and introducing infection. In addition, the acute cessation of intrathecal baclofen can precipitate a life-threatening withdrawal state. We report a case of successful epidural analgesia in a patient receiving intrathecal baclofen and discuss the steps we took to minimize the chance of harm with this technique. We conclude that an intrathecal catheter and subcutaneous pump to deliver baclofen should not preclude the use of an epidural catheter for perioperative analgesia.     

Successful management of a thoracic cerebrospinal fluid cutaneous fistula in a two year old child using a thoracic epidural blood patch

A case of persistent thoracic cerebrospinal fluid cutaneous fistula in a toddler following radiographically confirmed epidural catheter placement is reported. Treatment of the fistula with a thoracic epidural blood patch was successful.     

Intrathecal saline infusion in the treatment of obtundation associated with spontaneous intracranial hypotension: technical case report

OBJECTIVE AND IMPORTANCE: Spontaneous intracranial hypotension is an increasingly recognized cause of postural headache. However, appropriate management of obtundation caused by intracranial hypotension is not well defined. CLINICAL PRESENTATION: A 43-year-old man presented with postural headache followed by rapid decline in mental status. Imaging findings were consistent with the diagnosis of spontaneous intracranial hypotension, with bilateral subdural hematomas, pachymeningeal enhancement, and caudal displacement of posterior fossa structures and optic chiasm. INTERVENTION: Despite treatment with lumbar epidural blood patch, worsening stupor necessitated intubation and mechanical ventilation. Contrast-enhanced magnetic resonance imaging and computed tomographic myelography of the spine failed to demonstrate the site of cerebrospinal fluid fistula. The enlarging subdural fluid collections were drained, and a ventriculostomy was performed. Postoperatively, the patient remained semicomatose. To restore intraspinal and intracranial pressures, intrathecal infusion of saline was initiated. After several hours of lumbar saline infusion, lumbar and intracranial pressures normalized, and the patient's stupor resolved rapidly. Repeat computed tomographic myelography accomplished via C1-C2 puncture demonstrated a large ventrolateral T1-T3 leak, which was treated successfully with a thoracic epidural blood patch. Follow-up magnetic resonance imaging demonstrated resolution of intracranial hypotension, and the patient was discharged in excellent condition. CONCLUSION: Spontaneous intracranial hypotension may cause a decline of mental status and require lumbar intrathecal saline infusion to arrest or reverse impending central (transtentorial) herniation. This case demonstrates the use of simultaneous monitoring of lumbar and intracranial pressures to appropriately titrate the infusion and document resolution of intracranial hypotension. Maneuvers aimed at sealing the cerebrospinal fluid fistula then can be performed in a less emergent fashion after the patient's mental status has stabilized.     

Cranial nerve palsy and intracranial subdural hematoma following implantation of intrathecal drug delivery device

BACKGROUND AND OBJECTIVES: Complications related to cerebrospinal fluid (CSF) leak and low CSF pressure can occur following placement of an intrathecal drug delivery device. METHODS: A 58-year-old man with chronic, intractable lower back pain underwent implantation of an intrathecal drug delivery device. On the fourth postoperative day, he developed a postural headache and diplopia with findings compatible with left sixth cranial nerve palsy. The headache subsequently became constant and nonpostural. Cranial magnetic resonance imaging was obtained that showed the presence of a posterior subdural intracranial hematoma. Conservative treatment for postdural puncture headache did not improve the symptomatology. Therefore, an epidural blood patch was performed that produced rapid improvement and eventual resolution of symptoms. CONCLUSIONS: Intrathecal catheter implantation can result in CSF loss that might not resolve promptly with conservative therapy. In this case, epidural blood patch proved to be a safe and effective form of treatment.     

Reversal of an unintentional spinal anesthetic by cerebrospinal lavage

In this case report, we describe the use of cerebrospinal fluid lavage as a successful treatment of an inadvertent intrathecally placed epidural catheter in a 14-yr-old girl who underwent a combination of epidural anesthesia and general anesthesia for orthopedic surgery. In this case, a large amount of local anesthetic was injected (the total possible intrathecal injection was 200 mg of lidocaine and 61 mg of bupivacaine), resulting in apnea and fixed dilated pupils in the patient at the end of surgery. Twenty milliliters of cerebrospinal fluid was replaced with 10 mL of normal saline and 10 mL of lactated Ringer's solution from the "epidural" catheter. Spontaneous respiration returned 5 min later, and the patient was tracheally extubated after 30 min. No signs of neurological deficit or postdural puncture headache were noted after surgery. IMPLICATIONS: Cerebrospinal lavage may be a helpful adjunct to the conventional supportive management of patients in the event of an inadvertent total spinal.     

Epidural blood patch for treatment of subarachnoid fistula in children

A subarachnoid-cutaneous fistula developed in two children after the placement of a catheter in the subarachnoid space for drainage of cerebrospinal fluid. The management of this iatrogenic complication with epidural blood patch is described.     

Multicentre clinical simulation evaluation of the ISO 80369-6 neuraxial non-Luer connector

To avoid potentially fatal wrong-route neuraxial drug errors, international standard ISO 80369-6 specifying a non-Luer neuraxial connector design was published in 2016. We describe usability studies used in development of the design. Thirty-eight doctors and 17 nurses performed simulated procedures on manikins, using devices fitted with Luer connectors or draft ISO 80369-6 ‘non-Luer’ connectors. The procedures included spinal anaesthesia; intrathecal chemotherapy; lumbar puncture, cerebrospinal fluid collection and pressure measurement; epidural catheter placement with bolus injection and critical care use. Participants attempted cross connection between neuraxial connectors and a range of other medical device connectors, including those from the ISO 80369 small-bore connector series. Video recording analysis was used for all assessments. Participants subjectively assessed performance of the draft non-Luer connector, including suitability for routine clinical use. Participants performed 198 procedures. The connector achieved easy, leak-free connections. The willingness of participants to use the non-Luer connectors were: spinal anaesthesia 100%; intrathecal chemotherapy 88%; lumbar puncture, cerebrospinal fluid collection and pressure measurement 93%; epidural catheter placement with bolus injection 78%; critical care use 100%. Concerns raised were generally device related, rather than connector related. Most cross-connection attempts failed, even using above clinical forces and, when successful, were judged of low clinical risk potential; the exception was a malaligned connection between the non-Luer slip and female Luer connectors. This led to revision of the dimensional tolerances of the non-Luer connector to reduce this risk, before publication of the final specification in 2016. We conclude that the ISO 80369-6 neuraxial non-Luer connector is suitable for clinical use.     

A combined spinal-epidural technique for labor analgesia and symptomatic relief in two parturients with idiopathic intracranial hypertension

Idiopathic intracranial hypertension is a condition consisting of increased intracranial pressure of unknown etiology, predominantly affecting obese women of childbearing age. Symptomatic relief can be provided by lumbar puncture and withdrawal of cerebrospinal fluid, and the technique has been described in laboring women using an intrathecal catheter. We present two patients who achieved both labor analgesia and symptomatic relief via a combined spinal-epidural technique with small volume cerebrospinal fluid withdrawal. Both women complained of headache of at least a 5 on a 10-point pain scale at the time of labor induction. Between 5 and 6 mL of cerebrospinal fluid were withdrawn at the time of combined spinal-epidural insertion and pain relief was successfully achieved with patient-controlled epidural anesthesia. One patient proceeded to cesarean delivery for fetal indications under epidural anesthesia. Both women described significant improvement in headache symptoms that persisted until discharge from hospital, and neither developed new neurologic symptoms. A combined spinal-epidural technique with a small volume of cerebrospinal fluid withdrawal may provide labor analgesia and symptomatic relief in the parturient with idiopathic intracranial hypertension.     

The effect of placement and management of intrathecal catheters following accidental dural puncture on the incidence of postdural puncture headache and severity: a retrospective real-world study

Accidental dural puncture during an attempt to establish labour epidural analgesia can result in postdural puncture headache and long-term debilitating conditions. Epidural blood patch, the gold standard treatment for this headache, is invasive and not always successful. Inserting an intrathecal catheter after accidental dural puncture may prevent postdural puncture headache. We evaluated the effect of intrathecal catheter insertion on the incidence of postdural puncture headache and the need for epidural blood patch and whether duration of intrathecal catheterisation or injection of intrathecal saline affected outcome. Our retrospective study was conducted at two tertiary, university-affiliated medical centres between 2017 and 2022 and included 92,651 epidurals and 550 cases of accidental dural puncture (0.59%); 219 parturients (39.8%) received an intrathecal catheter and 331 (60.2%) a resited epidural. Use of an intrathecal catheter versus resiting the epidural did not decrease the odds of postdural puncture headache, adjusted odds ratio (aOR) (95%CI) 0.91 (0.81–1.01), but was associated with a lower need for epidural blood patch (aOR (95%CI) 0.82 (0.73–0.91), p < 0.001). We found no benefit in leaving in the intrathecal catheter for 24 h postpartum (postdural puncture headache, aOR (95%CI) 1.01 (1.00–1.02), p = 0.015; epidural blood patch, aOR (95%CI) 1.00 (0.99–1.01), p = 0.40). We found an added benefit of injecting intrathecal saline as it decreased the incidence of postdural puncture headache (aOR (95%CI) 0.85 (0.73–0.99), p = 0.04) and the need for epidural blood patch (aOR (95%CI) 0.75 (0.64–0.87), p < 0.001). Our study confirms the benefits of intrathecal catheterisation and provides guidance on how to best manage an intrathecal catheter.     

Intrathecal catheter use after accidental dural puncture in obstetric patients: literature review and clinical management recommendations

If an accidental dural puncture occurs, one option is to insert a catheter and use it as an intrathecal catheter. This avoids the need for a further injection and can rapidly provide labour analgesia and anaesthesia for caesarean section. However, there are no recommendations for managing intrathecal catheters and, therefore, significant variation in clinical practice exists. Mismanagement of the intrathecal catheter can lead to increased motor block, high spinal anaesthesia, drug error, hypotension and fetal bradycardia. Care must be taken with an intrathecal catheter to adhere to strict aseptic technique, meticulous labelling, cautious administration of medications and good communication with the patient and other staff. Every institution considering the use of intrathecal catheters should establish a protocol. For labour analgesia, we recommend the use of dilute local anaesthetic agents and opioids. For caesarean section anaesthesia, gradual titration to the level of the fourth thoracic dermatome, with full monitoring, in a facility equipped to manage complications, should be performed using local anaesthetics combined with lipophilic opioids and morphine or diamorphine. Although evidence of the presence and duration of intrathecal catheters on the development of post-dural puncture headache and need for epidural blood patch is limited, we suggest considering leaving the intrathecal catheter in for 24 hours to reduce the chance of developing a post-dural puncture headache while maintaining precautions to avoid drug error and cerebrospinal fluid leakage. Injection of sterile normal saline into the intrathecal catheter may reduce post-dural puncture headache. The level of evidence for these recommendations was low.     

A case of cerebrospinal fluid hypovolemia caused by Ommaya reservoir successfully treated by epidural blood patch

Here, we report a case of cerebrospinal fluid hypovolemia caused by lumbar puncture for implantation of an Ommaya reservoir. A 55-year-old man with central nervous system lymphoma developed meningeal dissemination. He was treated by spinal radiotherapy, and had an Ommaya reservoir implanted for intrathecal injection of anticancer drugs. After one month, he complained of orthostatic neck pain. MRI revealed bilateral subdural effusion and diffuse meningeal enhancement. He was diagnosed as having cerebrospinal fluid hypovolemia. Because no improvement in symptoms was seen after 2 weeks of conservative treatment, he was treated by a lumbar epidural blood patch. Subsequently symptoms improved markedly, and bilateral subdural effusion and diffuse meningeal enhancement disappeared on follow-up MRI.     

腰大池置管持续引流治疗胸椎黄韧带骨化术后脑脊液漏

目的探讨腰大池置管持续引流治疗胸椎黄韧带骨化术后脑脊液漏的效果。方法2003年3月～2011年3月对15例胸椎黄韧带骨化术后脑脊液漏应用一次性颅脑外引流器从L3-4椎间隙行硬膜外穿刺,置管于蛛网膜下腔引流脑脊液。结果切口引流时间2～8d,平均4d;腰大池置管时间3～10d,平均6d。15例术后随访6个月,无一例出现脑脊液复发、切口感染和颅内感染并发症。结论腰大池置管持续引流治疗胸椎黄韧带骨化术后脑脊液漏安全、有效。     

A comparison of epidural and cerebrospinal fluid glucose in parturients at term: an observational study

BackgroundDetecting inadvertent dural puncture during labour epidural insertion can be difficult when using a loss of resistance to saline technique. Testing fluid for glucose that leaks from a Tuohy needle may confirm the presence of cerebrospinal fluid and infer inadvertent dural puncture. This study compared the glucose content of intrathecal fluid obtained during spinal anaesthesia for elective caesarean delivery with that of fluid from a Tuohy needle or epidural catheter when establishing epidural analgesia for labour.MethodsWomen aged ?18 years undergoing elective caesarean delivery and labouring parturients who requested epidural analgesia were recruited prospectively in a tertiary referral centre over a three-month period. Fluid was collected into a sterile container either during spinal anaesthesia or from a labour epidural needle. Glucose content was evaluated using a bedside blood glucometer and laboratory colorimetric analyzer.ResultsOf the 118 women approached, 115 participated. All 40 women having spinal anaesthesia and 2/75 (2.7%) women having epidural analgesia, in whom inadvertent dural puncture was subsequently confirmed, had fluid samples testing positive for glucose. Median [range] laboratory glucose readings were 2.9 [1.3–5.1] mmol/L for cerebrospinal fluid and <0.3 mmol/L in fluid that leaked from a Tuohy needle (P = 0.0001).ConclusionWhen using a loss of resistance to saline technique for epidural catheter placement, bedside glucometer testing of fluid leaking from the epidural needle may be of value in the early detection of inadvertent dural puncture.     

Combined spinal epidural anaesthesia: a new technique

A new technique is described for delivering combined spinal epidural anaesthesia. The disadvantages of the needle-through-needle technique and the two-needle techniques are discussed. The new technique is a modification of the two-needle technique. The spinal needle is introduced and once cerebrospinal fluid is seen at the hub of the needle, the stylet is replaced. The epidural space is then identified and the epidural catheter placed. The spinal needle obturator is then removed and intrathecal injection performed. This technique avoids problems associated with placing an epidural catheter after an intrathecal injection and the potential problem of placing a spinal needle when an epidural catheter has already been placed. This technique requires further evaluation.     

Intracranial hypotension caused by leakage of cerebrospinal fluid from the thecal sac after lumboperitoneal shunt placement. Case report

The authors describe a newly recognized complication of lumboperitoneal (LP) shunt placement, namely, intracranial hypotension from leakage of cerebrospinal fluid (CSF) through a defect in the lumbar dura created by the shunt catheter. They report on a 47-year-old obese woman with idiopathic intracranial hypertension who underwent routine placement of an LP shunt. Following surgery, her headache became worse. Two radionuclide shunt studies showed no anterograde tracer flow, suggesting either obstruction or a leak. After shunt reservoir manometry indicated low pressure, spinal magnetic resonance (MR) imaging was performed. The MR images revealed a CSF leak from the lumbar thecal sac. A computed tomography (CT) myelogram, performed by injection into the shunt reservoir, confirmed the presence of a leak by showing extravasation of contrast agent into the epidural space. The patient was treated by application of a CT-guided blood patch at the leak site. Catheter-associated CSF leak is an unusual cause of intracranial hypotension that can occur following LP shunt placement. This case report outlines the clinical features of this condition, documents the neuroradiological findings, and demonstrates successful treatment with a blood patch.     

Persistent cerebrospinal fluid leak: a complication of the combined spinal-epidural technique

Persistent cerebrospinal fluid (CSF) leak is an apparently rare complication of dural puncture from spinal or epidural anesthesia. Combined spinal-epidural techniques are increasingly popular but persistent CSF leak has not been reported. We describe three parturients with persistent fluid leak from the insertion site after epidural catheter removal following combined spinal-epidural anesthesia. Uncertainties related to the diagnosis, treatment, and the implications of this complication are discussed, including beta(2)-transferrin immunofixation assay as a diagnostic test for the presence of CSF in this situation. IMPLICATIONS: Combined spinal-epidural block can be complicated by persistent fluid leak from the skin insertion site. Testing for the presence of cerebrospinal fluid may be a useful aid to management.     

An observational cohort study of the meniscus test to detect intravascular epidural catheters in pregnant women

BackgroundThe meniscus test is a rapid non-pharmacologic method of confirming epidural catheter placement by observing a normal saline meniscus while physically manipulating the catheter. The aim of this study was to assess whether the meniscus test improves diagnostic accuracy of aspiration to detect intravascular or intrathecal placement of epidural catheters in pregnant women.MethodsIn this prospective observational study, parturients at ?36 weeks of gestation were recruited. In the sitting position, participants received a multiorifice epidural catheter for elective cesarean delivery or labor analgesia. After aspiration was confirmed to be negative for blood and cerebrospinal fluid, the meniscus test was performed. Subsequently, a pharmacologic test dose was given with 1.5% lidocaine 3 mL and epinephrine 15 μg. Intravascular placement was diagnosed if the patient experienced an increase in heart rate ?20 beats/min within 2 min with or without tinnitus, metallic taste, dizziness, palpitations, headache, or anxiety.ResultsThe overall intravascular catheter rate was 5.7% (24/419). The rate of intravascular catheter location not detected by aspiration was 0.95% (4/419). Given negative catheter aspiration, the meniscus test demonstrated 25% sensitivity, 87.5% specificity, and 1.9% positive predictive value for intravascular catheter insertion. No intrathecal catheters were observed.ConclusionsFor obstetric patients in the sitting position, the meniscus test does not improve diagnostic accuracy of aspiration for detecting intravascular multiorifice epidural catheter placement.     

Antinociceptive and hemodynamic effects of a novel alpha2-adrenergic agonist, MPV-2426, in sheep.

BACKGROUND: alpha2-Adrenergic agonists produce analgesia primarily by a spinal action and hypotension and bradycardia by actions at several sites. Clonidine is approved for epidural use in the treatment of neuropathic pain, but its wider application is limited by hemodynamic side effects. This study determined the antinociceptive and hemodynamic effects of a novel alpha2-adrenergic agonist, MPV-2426, in sheep. METHODS: Forty sheep of mixed Western breeds with indwelling catheters were studied. In separate studies, antinociception to a mechanical stimulus, hemodynamic effects, arterial blood gas tensions, cerebrospinal fluid pharmacokinetics, and spinal cord blood flow was determined after epidural, intrathecal, and intravenous injection of MPV-2426. RESULTS: MPV-2426 produced antinociception with greater potency intrathecally (ED50 = 49 microg) than epidurally (ED50 = 202 microg), whereas intravenous administration had no effect. Intrathecal injection, in doses up to three times the ED95, failed to decrease systemic or central arterial blood pressures or heart rate, whereas larger doses, regardless of route, increased systemic arterial pressure. Bioavailability in cerebrospinal fluid was 7% after epidural administration and 0.17% after intravenous administration. Intrathecal MPV-2426, in an ED95 dose and three times this dose, produced a dose-independent reduction in thoracic and lumbar spinal cord blood flow. CONCLUSIONS: MPV-2426 shares many characteristics of other alpha2-adrenergic agonists examined in sheep, but differs from clonidine and dexmedetomidine by lack of antinociception and minimal reduction in oxygen partial pressure after large intravenous and epidural injections. No hemodynamic depression was observed after intrathecal injection at antinociceptive doses. These results suggest this compound may be an effective spinal analgesic in humans with less hypotension than clonidine, although its relative potency to cause sedation was not tested in this study.     

Multiport epidural catheters: does the air test work?

BACKGROUND: Multiport epidural catheters are popular; however, the reliability of the air test has not been evaluated with this catheter design. The authors determined the effectiveness of aspirating for blood and the air test in detecting intravascular multiorifice epidural catheters. METHODS: Three hundred women in labor underwent placement of a blunt-tip, three-hole, 20-gauge, lumbar epidural catheter. If there were no signs of spinal anesthesia, 3 ml lidocaine or bupivacaine was injected and the patient was observed for signs of spinal anesthesia. If there were no signs of spinal anesthesia, the authors injected 1 ml air through the epidural catheter while listening to the maternal precordium using a Doppler fetal heart rate monitor. Catheters through which blood was aspirated were air-tested and replaced. Patients with air-test-positive, blood-aspiration-negative catheters received 100 mg lidocaine through the catheter and were questioned about toxicity symptoms. The authors injected bupivacaine-fentanyl through aspiration-negative,air-test-negative catheters and recorded the sensory analgesic level 20 min later. RESULTS: The authors aspirated cerebrospinal fluid through one catheter and documented intravascular placement in 11 catheters. Results of the air test and blood aspiration were positive for eight catheters. Blood could not be aspirated from one air-test-positive catheter; perioral numbness developed in the patient after lidocaine injection. Blood was freely aspirated from two air-test-negative catheters. In the remaining 288 catheters, bupivacaine-fentanyl injection produced epidural analgesia in 279 patients and no effect in 9 patients. CONCLUSIONS: The authors obtained false-negative results with both catheter aspiration and the air test. Fractionating the local anesthetic dose is important when using multiorifice epidural catheters.     

Long-term intrathecal infusion of morphine in the home care of patients with advanced cancer

Background: Fear of infections and other complications has made many clinicians avoid intrathecal application of morphine in chronic cancer pain. However, recent comparative studies show that, in long-term treatment, intrathecal morphine administration may give a more satisfactory pain relief with lower doses of morphine and fewer side-effects than epidural administration. In Montpellier Cancer Institute, first cancer pain patients received long-term intrathecal morphine as early as in 1979, and since then more than 400 patients have been treated.
Methods: In 1991–1994, 50 patients having refractory cancer pain were treated with a continuous intrathecal infusion of morphine using an external pump with patient-controlled boluses. In this retrospective study, the outcome of these 5602 days of morphine therapy will be analysed. The treatment consisted of a lateral puncture technique, strictly aseptic conditions during catheter insertion and changes of pump reservoirs, and effective prevention of side-effects.
Results: The average duration of intrathecal infusion was 142 (7–584) days. The mean starting dose, 2.5 (0.4–8.3) mg/day, increased to a mean final dose of 9.2 (1–94) mg/day, the average dose being 5.4 (1–23) mg/day. During the treatment period, no clinically detectable infections and no respiratory depression occurred. Leakage of cerebrospinal fluid followed by post-spinal headache occurred in only 6 patients who received a temporary external catheter: the lateral lumbar puncture technique seemed to protect from this complication in long-term treatment. The patients stayed at home, coming to agreed control visits only at 4–6-week intervals, using a telephone-telefax service for emergencies.
Conclusions: Long-term intrathecal morphine infusion seems to provide satisfactory analgesia, few side-effects and a high degree of patient autonomy.