Skip to main content

Epidural catheter... another location to die in..

After passing the epidural catheter through the Ligamentum Flavum we expect the catheter to end up in the epidural space (best)..somtimes intrathecal( sure less good)..and rarely in the subdural(even more less good)...but now there is another place that epidural catheter may end up....

According to a study publised in Anaesthesia intensive care 2011 Nov;39(6):1038-42 .The authors (Collier, Reina et al) suggest the existence of a fourth space.

Failed epidurals


In some of these patients, radiological studies showed restricted spread of contrast injected into the failed epidurals.

 This striking compartmentalisation that you see in the above photo  , didn’t look at all like any spread you would expect from epidural or subdural injections.

The fourth space
The authors realized this could represent ‘a fourth space’, more precisely located within the dura.



Next, the authors obtained samples of the epidural sac from cadavers and analyzed them.

After preparing the samples the authors could, in some of them, clearly identify anomalous separations of the laminae that make up the dura.

The separations could expand into compartments, the intradural spaces.

They also documented how an epidural catheter can fit into one of these intradural spaces.

 The above photo shows an 20G epidural catheter passing through one of these intradural space.

This could be the answer to some epidural fails that we anaesthetists otherwise struggle to explain.
Labels:

Comments

Post a Comment

Popular posts from this blog

power injectable peripherally inserted central catheters

Clinical experience with power injectable peripherally inserted central catheters in intensive care patients     Introduction In intensive care units (ICU), peripherally inserted central catheters (PICC) may be an alternative option to standard central venous catheters, particularly in patients with coagulation disorders or at high risk for infection. Some limits of PICCs (such as low flow rates) may be overcome by the use of power-injectable catheters . Method We have retrospectively reviewed all the power injectable PICCs inserted in adult and pediatric patients in the ICU during a 12-month period, focusing on the rate of complications at insertion and during maintenance. Results We have collected 89 power injectable PICCs (in adults and in children), both multiple and single lumen. All insertions were successful. There were no major complications at insertion and no episodes of catheter-related blood stream infection. Non-infective complications ...
1 comment
Read more

The 12 decision making steps for post dural puncture headache treatment

Treatment decision-making algorithm for postdural puncture headache. 1. When diagnosis is made, all patients should receive supportive measures (reassurance, bed rest, analgesics, hydration, quiet environment). 2. Severity of symptoms should be classified using VAS scale (mild 1–3, moderate 4–6, severe 7–10). 3. Virtually all patients will improve in time even without additional therapy. (dashed lines) 4. Symptoms worsen or fail to resolve within 5 days. 5. Patient preference dictates the choice between pharmacologic (less effective) and epidural blood patch (EBP). 6. In patients with severe symptoms, EBP is strongly suggested. 7. The most common pharmacologic measure is  caffeine  prescription. 8. The failure, worsening, or recurrence of symptoms after pharmacologic measures favors the use of EBP. 9. In addition to EBP, other epidural treatment options can be considered in select patients (eg,  dextran , saline). 10. A period of 24 h should lapse before repeating EBP. 11...
1 comment
Read more

Things to Avoid in Anesthesia for Pregnant with Pulmonary hypertension

Anesthesia for Pregnant woman with Pulmonary Hypertension is a real challenge for anesthesiologist. It is very crucial to remember the pathophysiology of pulmonary hypertension in pregnant women and to avoid some practices that will worsen the cardiac status. 1-Avoid single shot spinal anesthesia. Some authorities consider pulmonary hypertension as absolute contraindication for single shot spinal anesthesia specially in patients with NYHA III ,IV. Spinal anesthesia causes major hemodynamic instability(decrease SVR, decrease VR, decrease in CO) The preferred neuroaxial techniques are (epidural anesthesia and CSE with minimal spinal dose) 2-Avoid PAC. Pulmonary Artery catheters insertion may lead to pulmonary artery rupture or thrombosis. TEE is better cardiac monitor/Arteial line is mandatory. 3-Avoid Nitrous oxide in gas mixture.N2O increase the PVR 4-If MV to be started, avoid High TV and PEEP 5-Avoid Oxytocin Boluses, or rapid administration of Pitocin. Oxytocin causes ...
Post a Comment
Read more