A 45‐year‐old, 68 kg woman underwent a total abdominal hysterectomy via a Pfannenstiel incision for which she received combined spinal and epidural (CSE) anaesthesia at the L3–L4 interspace. It was intended that the surgery would be completed using the CSE as the sole anaesthetic. For the spinal anaesthetic, 3.4 ml of hyperbaric bupivacaine 0.5% was used. The epidural catheter was sited, and following confirmation that there was no blood or cerebrospinal fluid (CSF) aspirated, the epidural catheter was flushed with 3 ml of normal saline. A sensory block was confirmed to the level of T6 using cold sensation, and dense motor block of both legs was observed. Thirty minutes after spinal anaesthesia, an epidural infusion of bupivacaine 0.25% was started at 6 ml.hr−1. Ninety minutes into the surgery, the patient reported generalised abdominal discomfort on surgical manipulation, which persisted despite two epidural boluses of 10 ml 0.25% bupivacaine. General anaesthesia was then induced, and the surgery was completed uneventfully. After the operation but still in theatre, a contrast study was carried out to check the position and determine if it would be useful for postoperative analgesia.
Figure 1 and online Supporting Information Video S1, both obtained with fluoroscopy in theatre, show the contrast study of the epidural catheter using 3 ml of Iohexol (OMNIPAQUE™ 240, GE HealthCare, Illinois, USA). This was used to determine the cause of epidural failure. The catheter was inserted at the L3–L4 interspace and is seen exiting through the L2–L3 intervertebral foramina on the left side. The contrast is seen staining the psoas digitations attached to the L1 and L2 transverse processes.
Figure 1.
Fluoroscopy image taken after injection of 3 ml of Iohexol via the epidural catheter. The yellow arrows highlight the epidural catheter fixed externally on the skin. The red arrow indicates the epidural catheter entering through the L3–L4 interspace. The green arrow shows the epidural catheter exiting the L2–L3 intervertebral foramina on the left side. The blue arrows show the contrast enhancing the two digitations of the psoas muscle arising from the L1 and L2 transverse processes.
Demonstrating a band of sensory loss is the best way to confirm the effective functioning of an epidural catheter. This confirmation is only possible however in patients who have received an epidural rather than an epidural as part of a CSE or if a general anaesthetic is administered before the development of sensory loss. Despite several advancements in epidural catheter material and tip designs, malpositioned epidural catheters continue to occur [1, 2, 3]. It is reported that 27% of lumbar epidurals fail but, in many cases, the underlying cause for the failure is undetermined [4]. Fluoroscopy facilitates quick confirmation in theatre and may inform decision‐making including an alternative post‐operative anaesthetic or analgesic plan.
Supporting information
Video S1. The video was recorded using fluoroscopy as the contrast was injected through the epidural catheter. It shows the epidural catheter entering through the L3–L4 interspace, exiting the L2–L3 intervertebral foramina on the left side and the contrast enhancing the two digitations of the psoas muscle arising from the L1 and L2 transverse processes.
Acknowledgements
Published with the written consent of the patient. No funding and no conflicts of interest to declare.
1 Senior Resident, 2 Junior Resident, 3 Additional Professor, 4 Director and CEO, 5 Professor, Department of Anaesthesiology, All India Institute of Medical Sciences, Mangalagiri, India
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Associated Data
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Supplementary Materials
Video S1. The video was recorded using fluoroscopy as the contrast was injected through the epidural catheter. It shows the epidural catheter entering through the L3–L4 interspace, exiting the L2–L3 intervertebral foramina on the left side and the contrast enhancing the two digitations of the psoas muscle arising from the L1 and L2 transverse processes.