Reactions 1302 - 22 May 2010

SBupivacaine/fentanyl

Back pain and failed epidural block followinginadvertent subdural catheterisation: case report

A 33-year-old woman developed severe back pain andexperienced a failed epidural block following bupivacaineand fentanyl administration for labour analgesia.

The woman presented for labour induction at 41 weeksof gestation. Following an unsuccessful epiduralcatheterisation, she received intrathecal isobaricbupivacaine 0.5% 1.75mg and fentanyl 15µg (total of 1mg).An epidural catheter was then threaded and an infusion of0.0625% bupivacaine with fentanyl 2 µg/mL was startedwith patient-controlled analgesia (PCEA), at a baseline of10 mL/h, bolus 5mL, lockout 10 minutes and a limit of40 mL/hour. Six hours later, at full cervical dilatation, sheagain experienced severe pain which persisted despitetwo bolus doses of PCEA followed by 8mL of0.125% bupivacaine. The epidural catheter was pulled back1cm and two 5mL doses of 0.25% bupivacaine were givenover 10 minutes. Her labour pains were relieved but shedeveloped severe pain from her neck to the lower back,particularly between the scapulae; the pain resolvedgradually over the next 30 minutes. After 5 hours, adecision was made to perform a caesarean section. Whilewaiting, she again developed contraction pain. Two 5mLdoses of 0.25% bupivacaine resulted in back and neck painduring the injection. Twenty minutes after the bolusinjection, her labour pain was not relieved. An attempt wasmade to replace the epidural catheter at a higher level. Afteran apparent unintentional dural puncture, a catheter wasthreaded through the presumed intrathecal space and shewas transferred to the operating theatre. To induce surgicalanaesthesia, 1mL of isobaric 0.25% bupivacaine wasinjected, with no effect after 5 minutes. Another two dosesfailed to induce anaesthesia. Twenty five minutes later,general anaesthesia was induced and she underwent anuncomplicated cesarean delivery where she received IVmorphine. Three hours after recovering from generalanaesthesia, electrical stimulation of the catheter elicitedunilateral muscle twitches on the right thigh. Three hourslater, fluoroscopic x-ray examination of the spinal columnshowed radio-opaque contrast dye in the subdural space.Minutes after the final contrast injection, she developedsevere neck and shoulder pain, which subsided 15 to30 minutes after IV morphine.

The woman received post-operative analgesia with IVpatient-controlled morphine, diclofenac sodium andparacetamol [acetaminophen]. The epidural catheter waseventually removed and she made an uneventful recoverywith no post-dural puncture headache or otherneurological manifestations.Moore AR, et al. Unintentional subdural catheter placement during labor analgesiashows typical radiological pattern but atypical response to the Tsui test.International Journal of Obstetric Anesthesia 19: 111-4, No. 1, Jan 2010 -Canada 803015668

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Reactions 22 May 2010 No. 13020114-9954/10/1302-0001/$14.95 © 2010 Adis Data Information BV. All rights reserved