725
Anesth Analg 56: 725-735.1977
Clinical Reports Latent Dural Puncture After Lumbar Epidural Block JEROME A. ROBSON, M D * JAY B. BRODSKY, M D t Son Francisco, California$
U
dural puncture during lumbar peridural block can occur with placement of the introducer needle and cannulation of the peridural space or, rarely, during the course of the anesthetic. This case report describes an unusual intraoperative presentation and early detection of such a dural perforation. NINTENTIONAL
administered. Laboratory analysis of the aspirated fluid confirmed the diagnosis of dural puncture with the following results: glucose, 329 mg/100 ml; total protein, 2.5 mg/100 ml; total bilirubin, 2.4 mg/100 ml. Additional reinforcement doses of 4 ml of 1.5 percent lidocaine were given at approximately hourIy intervals on 2 more occasions. T h e patient underwent a cholycystojejunostomy and gastroenterostomy without further complications.
REPORT OF A CASE A 54-year-old man with adenocarcinoma of the pancreas was scheduled for an explorCOMMENT atory laparotomy. The patient’s preoperaInadvertent dural puncture occurs in aptive serum total bilirubin was 19 mg/100 ml. Lumbar epidural anesthesia for intra- and proximately 2 to 3.3 percent of peridural postoperative analgesia was planned with blocks.1,’ The majority of unintentional N,O/O, supplementation. A polyvinylchlo- punctures occurring during needle or cathride catheter was placed in the epidural eter placement are usually identified by asspace at the L, level without complication. piration of spinal fluid. An anesthetic test After the catheter was aspirated without dose will further identify an unsuspected fluid return, an anesthetic test dose of 4 ml dural puncture by producing a high level of of 1.5 percent lidocaine was administered, anesthesia. Less frequently, catheter dural followed 5 minutes later by 16 ml of 1.5 per- puncture may occur intraoperatively. This cent lidocaine with epinephrine (1:200,000 complication was not noted in 1180 cases of concentration). A sensory block to T, was catheter epidurals reported in 1 series.l achieved. Ninety minutes later, after nega- Moore3 describes 3 cases of intraoperative tive aspiration of the catheter, a dose of 12 dural perforation by metal needles which ml of 1.5 percent lidocaine was injected. were left intentionally in the peridural After an hour, aspiration of the catheter, space. Pulsations of the dura against the prior to administration of a 3rd anesthetic needle or plastic catheter could result in dose, yielded clear xanthochromic fluid with dural erosion. Negative pressure from the pH 7.45. The anesthetic was then converted aspirating syringe may pull the dura against to a continuous subarachnoid technic and a the catheter, leading to puncture. If unrecdose of 4 ml of 1.5 percent lidocaine was ognized dural puncture occurs, the rein*Resident. $Staff Anesthesiologist.
$Anesthesiology and Operative Service, Department of Surgery, Letterman Army Medical Center, Presidio of San Francisco, California. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense. Requests for reprints to: Technical Publications Editor, Letterman Army Medical Center, Presidio of San Francisco, CA 94129. Paper received: December 16, 1976 Accepted for publication: January 25, 1977
726 forcement anesthetic dose will produce a ral perforation had occurred, and the volume of drug to be administered was reduced, high spinal block. A recent report4 described the appearance thereby avoiding a high or “total” spinal of total spinal anesthesia late in the course anesthesia. of an uneventful lumbar epidural block. The REFERENCES authors could only assume that the dura 1. Bonica JJ, Backup PH, Anderson CE, et al: had been penetrated, since the catheter had Peridural block: analysis of 3637 cases and a review. not been aspirated prior to the reinforce- Anesthesiology 18:723-784, 1957 ment dose of the anesthetic. Spinal fluid 2. Hehre FW, Savig JM: Continuous lumbar and local anesthetic can be differentiated by peridural anesthesia in obstetrics. Am J Obstet testing the temperature and viscosity,3 or Gynec 80:1173-1180, 1960 glucose and pH,S although pH testing is not 3. Moore DC: Regional Block Anesthesia. Fourth infallible.6 If spinal fluid is aspirated, a edition. Springfield, Illinois, Charles C Thomas, continuous epidural technic can be changed Publisher, 1969 to a continuous subarachnoid technic by 4. Philip J H , Brown WV: Total spinal anesadministering the appropriate volume of thesia late in the course of obstetric bupivacaine epidural block. Anesthesiology 44:340-341, 1976 anesthetic. 5. Reisner LS: Epidural test solution or spinal In the present case, the unusual appear- fluid? Anesthesiology 44:451, 1976 ance of xanthochromic spinal fluid upon 6. Rosenberg H: pH in differentiating CSF from aspiration of the epidural catheter alerted local anesthetics in epidural anesthesia. Anesthesithe anesthesiologist that intraoperative du- ology 45:579, 1976
A Foreign-Body Hazard in the Neonate JAY MILSTEIN, MD* JEFF RABINOVITZ, M D t BOYD GOETZMAN, MD, PhD$ Davis, California5
F
ORFXGN-BODY aspiration is unusual in the minutes, respectively. Following delivery, neonate, but the risks may now be in- tracheal suctioning was performed via an creased because of the more vigorous use endotracheal tubell. No meconium was reof direct tracheal suctioning and/or intuba- covered. After extubation, the baby coughed tion employed in neonates with suspected and expectorated a small elliptical plastic pneumonia, meconium aspiration, or requir- disc and was then asymptomatic. The physiing assisted ventilation. This report describes cal examination and subsequent neonatal a neonate with a foreign body in the airway course were unremarkable. Inspection of the disc revealed that it was the punched-out from such a procedure. portion of the side hole of the endotracheal The infant was the 3175-gram product of tube (figure). It apparently was still ata full-term, uncomplicated gestation. Intra- tached when the tube was packaged and partum monitoring revealed fetal distress. A nuchal cord and meconium staining were 11 Pediatric Murphy E T Tube, Shiley Laboratories, noted. Apgar scores were 8 and 9 a t 1 and 5 Santa Ana, California 92711.
”Neonatal Fellow. FResident in Pediatrics. SAssistant Professor of Pediatrics. PDepartment of Pediatrics, University of California, Davis, California 95616. Reprint requests to: Boyd Goetzman, M.D., Ph.D., Department of Pediatrics, 4301 X Street, Sacramento, California 95817. Paper received: December 27, 1976 Accepted for publication: January 27, 1977
Anesth Analg 56: 725-735.1977
Clinical Reports Latent Dural Puncture After Lumbar Epidural Block JEROME A. ROBSON, M D * JAY B. BRODSKY, M D t Son Francisco, California$
U
dural puncture during lumbar peridural block can occur with placement of the introducer needle and cannulation of the peridural space or, rarely, during the course of the anesthetic. This case report describes an unusual intraoperative presentation and early detection of such a dural perforation. NINTENTIONAL
administered. Laboratory analysis of the aspirated fluid confirmed the diagnosis of dural puncture with the following results: glucose, 329 mg/100 ml; total protein, 2.5 mg/100 ml; total bilirubin, 2.4 mg/100 ml. Additional reinforcement doses of 4 ml of 1.5 percent lidocaine were given at approximately hourIy intervals on 2 more occasions. T h e patient underwent a cholycystojejunostomy and gastroenterostomy without further complications.
REPORT OF A CASE A 54-year-old man with adenocarcinoma of the pancreas was scheduled for an explorCOMMENT atory laparotomy. The patient’s preoperaInadvertent dural puncture occurs in aptive serum total bilirubin was 19 mg/100 ml. Lumbar epidural anesthesia for intra- and proximately 2 to 3.3 percent of peridural postoperative analgesia was planned with blocks.1,’ The majority of unintentional N,O/O, supplementation. A polyvinylchlo- punctures occurring during needle or cathride catheter was placed in the epidural eter placement are usually identified by asspace at the L, level without complication. piration of spinal fluid. An anesthetic test After the catheter was aspirated without dose will further identify an unsuspected fluid return, an anesthetic test dose of 4 ml dural puncture by producing a high level of of 1.5 percent lidocaine was administered, anesthesia. Less frequently, catheter dural followed 5 minutes later by 16 ml of 1.5 per- puncture may occur intraoperatively. This cent lidocaine with epinephrine (1:200,000 complication was not noted in 1180 cases of concentration). A sensory block to T, was catheter epidurals reported in 1 series.l achieved. Ninety minutes later, after nega- Moore3 describes 3 cases of intraoperative tive aspiration of the catheter, a dose of 12 dural perforation by metal needles which ml of 1.5 percent lidocaine was injected. were left intentionally in the peridural After an hour, aspiration of the catheter, space. Pulsations of the dura against the prior to administration of a 3rd anesthetic needle or plastic catheter could result in dose, yielded clear xanthochromic fluid with dural erosion. Negative pressure from the pH 7.45. The anesthetic was then converted aspirating syringe may pull the dura against to a continuous subarachnoid technic and a the catheter, leading to puncture. If unrecdose of 4 ml of 1.5 percent lidocaine was ognized dural puncture occurs, the rein*Resident. $Staff Anesthesiologist.
$Anesthesiology and Operative Service, Department of Surgery, Letterman Army Medical Center, Presidio of San Francisco, California. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense. Requests for reprints to: Technical Publications Editor, Letterman Army Medical Center, Presidio of San Francisco, CA 94129. Paper received: December 16, 1976 Accepted for publication: January 25, 1977
726 forcement anesthetic dose will produce a ral perforation had occurred, and the volume of drug to be administered was reduced, high spinal block. A recent report4 described the appearance thereby avoiding a high or “total” spinal of total spinal anesthesia late in the course anesthesia. of an uneventful lumbar epidural block. The REFERENCES authors could only assume that the dura 1. Bonica JJ, Backup PH, Anderson CE, et al: had been penetrated, since the catheter had Peridural block: analysis of 3637 cases and a review. not been aspirated prior to the reinforce- Anesthesiology 18:723-784, 1957 ment dose of the anesthetic. Spinal fluid 2. Hehre FW, Savig JM: Continuous lumbar and local anesthetic can be differentiated by peridural anesthesia in obstetrics. Am J Obstet testing the temperature and viscosity,3 or Gynec 80:1173-1180, 1960 glucose and pH,S although pH testing is not 3. Moore DC: Regional Block Anesthesia. Fourth infallible.6 If spinal fluid is aspirated, a edition. Springfield, Illinois, Charles C Thomas, continuous epidural technic can be changed Publisher, 1969 to a continuous subarachnoid technic by 4. Philip J H , Brown WV: Total spinal anesadministering the appropriate volume of thesia late in the course of obstetric bupivacaine epidural block. Anesthesiology 44:340-341, 1976 anesthetic. 5. Reisner LS: Epidural test solution or spinal In the present case, the unusual appear- fluid? Anesthesiology 44:451, 1976 ance of xanthochromic spinal fluid upon 6. Rosenberg H: pH in differentiating CSF from aspiration of the epidural catheter alerted local anesthetics in epidural anesthesia. Anesthesithe anesthesiologist that intraoperative du- ology 45:579, 1976
A Foreign-Body Hazard in the Neonate JAY MILSTEIN, MD* JEFF RABINOVITZ, M D t BOYD GOETZMAN, MD, PhD$ Davis, California5
F
ORFXGN-BODY aspiration is unusual in the minutes, respectively. Following delivery, neonate, but the risks may now be in- tracheal suctioning was performed via an creased because of the more vigorous use endotracheal tubell. No meconium was reof direct tracheal suctioning and/or intuba- covered. After extubation, the baby coughed tion employed in neonates with suspected and expectorated a small elliptical plastic pneumonia, meconium aspiration, or requir- disc and was then asymptomatic. The physiing assisted ventilation. This report describes cal examination and subsequent neonatal a neonate with a foreign body in the airway course were unremarkable. Inspection of the disc revealed that it was the punched-out from such a procedure. portion of the side hole of the endotracheal The infant was the 3175-gram product of tube (figure). It apparently was still ata full-term, uncomplicated gestation. Intra- tached when the tube was packaged and partum monitoring revealed fetal distress. A nuchal cord and meconium staining were 11 Pediatric Murphy E T Tube, Shiley Laboratories, noted. Apgar scores were 8 and 9 a t 1 and 5 Santa Ana, California 92711.
”Neonatal Fellow. FResident in Pediatrics. SAssistant Professor of Pediatrics. PDepartment of Pediatrics, University of California, Davis, California 95616. Reprint requests to: Boyd Goetzman, M.D., Ph.D., Department of Pediatrics, 4301 X Street, Sacramento, California 95817. Paper received: December 27, 1976 Accepted for publication: January 27, 1977
