Correspondence
95 J. Ni, L. Luo, L. Wu, D. Luo Department of Anaesthesiology West China Second University Hospital Sichuan University Chengdu, Sichuan, China E-mail address: [email protected]
References 1. Mhyre JM, Riesner MN, Polley LS, Naughton NN. A series of anesthesia-related maternal deaths in Michigan, 1985–2003. Anesthesiology 2007;106:1096–104. 2. Hawkins JL, Chang J, Palmer SK, Gibbs CP, Callaghan WM. Anesthesia-related maternal mortality in the United States: 1979– 2002. Obstet Gynecol 2011;117:69–74. 3. Dhonneur G, Ndoko S, Amathieu R, Housseini LE, Poncelet C, Tual L. Tracheal intubation using the Airtraq in morbid obese patients undergoing emergency cesarean delivery. Anesthesiology 2007;106:629–30. 4. Lu Y, Jiang H, Zhu YS. Airtraq laryngoscope versus conventional Macintosh laryngoscope: a systematic review and meta-analysis. Anaesthesia 2011;66:1160–7. 5. Gaszynski TM. Forces applied by the laryngoscope blade onto the tongue during intubation attempts: a comparison between Macintosh, AirTraq and Pentax AWS in a mannequin study. Eur J Anaesthesiol 2011;28:463–4. 0959-289X/$ - see front matter
c 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ijoa.2013.08.006
Removal of a fractured spinal needle fragment six months after caesarean section The use of narrow-gauge spinal needles decreases the incidence of postdural puncture headache but may make correct placement more difficult, especially in obese patients. Several cases of deformation and fracture of narrow-gauge spinal needles have been reported,1–6 of which three were associated with obstetric anaesthetic practice.1–3 We report the diagnosis and subsequent removal of a fractured 27-gauge pencil-point needle six months after caesarean section (CS). A 30-year-old woman with a body mass index (BMI) of 30 kg/m2 who had undergone CS six months previously, visited her general practitioner for a routine check-up of her multiple sclerosis. Her symptoms were predominantly in her upper extremities. In addition to the scheduled magnetic resonance imaging (MRI) of her cervical spine, she insisted on additional MRI pictures of her lumbar spine because of persistent lower back pain since her CS. This revealed a strong metal artefact confirmed by a lumbar X-ray to be a needle fragment. Surgical removal, under general anaesthesia, revealed a severely bent 3–4 cm distal tip of a 27gauge pencil-point needle without the inner stylet (Fig. 1).
Fig. 1 Severely deformed distal fragment of a 27-gauge spinal needle without stylet.
The needle was sent to the manufacturer, Braun Medical, where it was examined microscopically. They concluded that the needle, without stylet inside, had broken because of the use of excessive force. They also measured the outer diameter of the needle which was within specification limits. The anaesthetic records of the CS describe numerous attempts with more than one needle (88-mm PencanÒ 27-gauge pencil-point, B Braun, Melsungen, Germany). A final attempt with a 25-gauge Quincke needle was successful. There was no documentation of a deformed or fractured spinal needle. The patient and her partner were upset that nobody appeared to have noticed the missing part of the needle at the end of the spinal procedure, and by the lack of routine for checking equipment. The case was presented to the Norwegian Patient Compensation (Norsk Pasientskade Erstatning), and is still under review. Following removal of the spinal needle fragment, the patient’s lower back pain subsided but did not fully disappear. Two subsequent MRI scans did not reveal any pathology at the lumbar level. The three previous cases of needle damage associated with spinal anaesthesia for CS all involved obese patients: our patient had a BMI of 30 kg/m2. All highlight multiple failed attempts, similar to our case. Extra-long spinal needles were used (115, 120 and 140 mm), but in our case a standard 88-mm needle was used. All cases, including ours, make note of bony resistance but not the use of excessive force. Two cases were as part of a combined spinal-epidural technique. In one using a needle-through-needle technique, the stylet was removed whilst advancing the spinal (115-mm 27-gauge Whitacre) and a 17-gauge Tuohy needle simultaneously awaiting the appearance of cerebrospinal fluid. After meeting slight resistance both needles were advanced but without the appearance of cerebrospinal fluid. Both
96
Correspondence
needles were then removed and the fracture noticed.1 In the second patient the epidural catheter and spinal needle were intentionally placed at separate levels. Several attempts at spinal anaesthesia were made at the third lumbar interspace. Eventually the 27-gauge Whitacre needle fractured, with the 5-cm distal part missing. It was not stated if the stylet was removed.2 The final obstetric case report describes several attempts with a 27-gauge needle with the stylet in place.3 We have carried out in vitro tests finding that, when manipulating an intact 27-gauge pencil-point needle, it is very difficult to fracture or to shear off the distal bent part against the introducer needle when the stylet is in place. However, when the needle is manipulated after the stylet is removed, it is much easier to break or shear off fragments. This is illustrated by two of the previous published case reports as well as ours. Narrower-gauge spinal needles, especially the longer variety, are more difficult to use, more so in obese patients. We agree with the recommendation made by Mehta7 and Brown8 that when difficulties occur with narrower needles, a needle-through-needle technique should be considered, where the epidural needle guides the spinal needle to the dura. Although not in widespread use, there has been recent interest in the use of ultrasound in facilitating placement of spinal or epidural needles, especially in obese patients.9 Redirection of a spinal needle should not occur with the stylet removed, nor should the introducer needle be redirected with the spinal needle passed beyond its distal tip. On complete withdrawal of the needle the introducer should be removed simultaneously to prevent shearing off the distal fragment. H. Lonne´e, S. Fasting Department of Anaesthesia and Intensive Care St Olavs Hospital, Trondheim, Norway E-mail address: [email protected]
References 1. Wendling AL, Wendling MT, Gravenstein D, Euliano TY. Fractured small gauge needle during attempted combined spinalepidural anaesthesia for cesarean delivery. Anesth Analg 2010;111: 245. 2. Abou-Shameh MA, Lyons G, Roa A, Mushtaque S. Broken needle complicating spinal anesthesia. Int J Obstet Anesth 2006;15: 178–9. 3. Greenway MW, Vickers R. Broken micro-tip spinal needle. Int J Obstet Anesth 2009;18:295–6. 4. Gentili ME, Nicol JB, Enel D, Marret E. Recovery of a spinal needle. Reg Anesth Pain Med 2006;31:186. 5. Thomsen AF, Nilsson CG. Broken small-gauge spinal needle. Anesth Analg 1997;85:230–1. 6. Cruvinel MGC, Andrade AVC. Needle fracture during spinal puncture. Rev Bras Anesthesiol 2004;54:794–8. 7. Metha M. Broken needle complicating spinal anaesthesia. Int J Obstet Anesth 2007;16:94–5.
8. Brown DL. Spinal, epidural and caudal anaesthesia. In: Miller RD editor. Anesthesia. 6th ed. Philadelphia: Churchill Livingstone; 2005. p. 1678. 9. Carvalho JCA. Ultrasound-facilitated epidurals and spinals in obstetrics. Anesth Clin 2008;26:145–58. 0959-289X/$ - see front matter
c 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ijoa.2013.08.006
Intraoperative hyperthermia during cesarean section: a pertinent lesson On a mission trip to a developing county, one of us (VF) managed a patient who developed intraoperative hyperthermia. She was a healthy 18-year-old nulliparous woman who underwent an emergency cesarean section under general anesthesia for fetal distress. Her preoperative examination was normal, malaria screening was negative and she was initially afebrile. She denied any previous abnormal reactions to anesthesia by herself or any family members. A routine rapid-sequence induction with thiopental 400 mg and succinylcholine 100 mg was used. A healthy child was delivered within 3 min. Oxytocin 5 IU was injected intravenously after the placenta was removed and an infusion of 20 IU in saline 500 mL was commenced. Anesthesia was maintained with 70% nitrous oxide in oxygen and halothane 0.6 vol%; atracurium 12.5 mg and meperidine 100 mg were given. Twenty minutes later, the axillary temperature rose to 39.0°C, and subsequently as high as 40.5°C. Penicillin 1 g was given intravenously. Her blood pressure remained stable at 110/70 mmHg but she had a persistent tachycardia of 120–130 beats/min. No muscle rigidity was noticed. A capnograph was not available. Surgery was completed in 70 min. After antagonism of residual neuromuscular block, spontaneous breathing resumed but she remained unconscious with stable vital signs except for tachycardia and pyrexia. Differential diagnosis of malignant hyperthermia was considered but the local anesthetic technician suggested malaria despite negative preoperative screening. Since dantrolene was not readily available, quinine 600 mg in 5% glucose 500 mL was given intravenously. Blood glucose concentration was checked hourly since it can be decreased by quinine.1 In the recovery room, cooling the patient with cold intravenous fluids and blankets soaked in cold water had little effect. Within 3 h of starting quinine her temperature decreased to 38°C and she regained consciousness. She was extubated in the recovery room and was transferred to the intensive care unit for one night. Subsequently, the laboratory confirmed the patient as having Plasmodium vivax malaria. She was discharged from the hospital with a healthy baby on day five.
95 J. Ni, L. Luo, L. Wu, D. Luo Department of Anaesthesiology West China Second University Hospital Sichuan University Chengdu, Sichuan, China E-mail address: [email protected]
References 1. Mhyre JM, Riesner MN, Polley LS, Naughton NN. A series of anesthesia-related maternal deaths in Michigan, 1985–2003. Anesthesiology 2007;106:1096–104. 2. Hawkins JL, Chang J, Palmer SK, Gibbs CP, Callaghan WM. Anesthesia-related maternal mortality in the United States: 1979– 2002. Obstet Gynecol 2011;117:69–74. 3. Dhonneur G, Ndoko S, Amathieu R, Housseini LE, Poncelet C, Tual L. Tracheal intubation using the Airtraq in morbid obese patients undergoing emergency cesarean delivery. Anesthesiology 2007;106:629–30. 4. Lu Y, Jiang H, Zhu YS. Airtraq laryngoscope versus conventional Macintosh laryngoscope: a systematic review and meta-analysis. Anaesthesia 2011;66:1160–7. 5. Gaszynski TM. Forces applied by the laryngoscope blade onto the tongue during intubation attempts: a comparison between Macintosh, AirTraq and Pentax AWS in a mannequin study. Eur J Anaesthesiol 2011;28:463–4. 0959-289X/$ - see front matter
c 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ijoa.2013.08.006
Removal of a fractured spinal needle fragment six months after caesarean section The use of narrow-gauge spinal needles decreases the incidence of postdural puncture headache but may make correct placement more difficult, especially in obese patients. Several cases of deformation and fracture of narrow-gauge spinal needles have been reported,1–6 of which three were associated with obstetric anaesthetic practice.1–3 We report the diagnosis and subsequent removal of a fractured 27-gauge pencil-point needle six months after caesarean section (CS). A 30-year-old woman with a body mass index (BMI) of 30 kg/m2 who had undergone CS six months previously, visited her general practitioner for a routine check-up of her multiple sclerosis. Her symptoms were predominantly in her upper extremities. In addition to the scheduled magnetic resonance imaging (MRI) of her cervical spine, she insisted on additional MRI pictures of her lumbar spine because of persistent lower back pain since her CS. This revealed a strong metal artefact confirmed by a lumbar X-ray to be a needle fragment. Surgical removal, under general anaesthesia, revealed a severely bent 3–4 cm distal tip of a 27gauge pencil-point needle without the inner stylet (Fig. 1).
Fig. 1 Severely deformed distal fragment of a 27-gauge spinal needle without stylet.
The needle was sent to the manufacturer, Braun Medical, where it was examined microscopically. They concluded that the needle, without stylet inside, had broken because of the use of excessive force. They also measured the outer diameter of the needle which was within specification limits. The anaesthetic records of the CS describe numerous attempts with more than one needle (88-mm PencanÒ 27-gauge pencil-point, B Braun, Melsungen, Germany). A final attempt with a 25-gauge Quincke needle was successful. There was no documentation of a deformed or fractured spinal needle. The patient and her partner were upset that nobody appeared to have noticed the missing part of the needle at the end of the spinal procedure, and by the lack of routine for checking equipment. The case was presented to the Norwegian Patient Compensation (Norsk Pasientskade Erstatning), and is still under review. Following removal of the spinal needle fragment, the patient’s lower back pain subsided but did not fully disappear. Two subsequent MRI scans did not reveal any pathology at the lumbar level. The three previous cases of needle damage associated with spinal anaesthesia for CS all involved obese patients: our patient had a BMI of 30 kg/m2. All highlight multiple failed attempts, similar to our case. Extra-long spinal needles were used (115, 120 and 140 mm), but in our case a standard 88-mm needle was used. All cases, including ours, make note of bony resistance but not the use of excessive force. Two cases were as part of a combined spinal-epidural technique. In one using a needle-through-needle technique, the stylet was removed whilst advancing the spinal (115-mm 27-gauge Whitacre) and a 17-gauge Tuohy needle simultaneously awaiting the appearance of cerebrospinal fluid. After meeting slight resistance both needles were advanced but without the appearance of cerebrospinal fluid. Both
96
Correspondence
needles were then removed and the fracture noticed.1 In the second patient the epidural catheter and spinal needle were intentionally placed at separate levels. Several attempts at spinal anaesthesia were made at the third lumbar interspace. Eventually the 27-gauge Whitacre needle fractured, with the 5-cm distal part missing. It was not stated if the stylet was removed.2 The final obstetric case report describes several attempts with a 27-gauge needle with the stylet in place.3 We have carried out in vitro tests finding that, when manipulating an intact 27-gauge pencil-point needle, it is very difficult to fracture or to shear off the distal bent part against the introducer needle when the stylet is in place. However, when the needle is manipulated after the stylet is removed, it is much easier to break or shear off fragments. This is illustrated by two of the previous published case reports as well as ours. Narrower-gauge spinal needles, especially the longer variety, are more difficult to use, more so in obese patients. We agree with the recommendation made by Mehta7 and Brown8 that when difficulties occur with narrower needles, a needle-through-needle technique should be considered, where the epidural needle guides the spinal needle to the dura. Although not in widespread use, there has been recent interest in the use of ultrasound in facilitating placement of spinal or epidural needles, especially in obese patients.9 Redirection of a spinal needle should not occur with the stylet removed, nor should the introducer needle be redirected with the spinal needle passed beyond its distal tip. On complete withdrawal of the needle the introducer should be removed simultaneously to prevent shearing off the distal fragment. H. Lonne´e, S. Fasting Department of Anaesthesia and Intensive Care St Olavs Hospital, Trondheim, Norway E-mail address: [email protected]
References 1. Wendling AL, Wendling MT, Gravenstein D, Euliano TY. Fractured small gauge needle during attempted combined spinalepidural anaesthesia for cesarean delivery. Anesth Analg 2010;111: 245. 2. Abou-Shameh MA, Lyons G, Roa A, Mushtaque S. Broken needle complicating spinal anesthesia. Int J Obstet Anesth 2006;15: 178–9. 3. Greenway MW, Vickers R. Broken micro-tip spinal needle. Int J Obstet Anesth 2009;18:295–6. 4. Gentili ME, Nicol JB, Enel D, Marret E. Recovery of a spinal needle. Reg Anesth Pain Med 2006;31:186. 5. Thomsen AF, Nilsson CG. Broken small-gauge spinal needle. Anesth Analg 1997;85:230–1. 6. Cruvinel MGC, Andrade AVC. Needle fracture during spinal puncture. Rev Bras Anesthesiol 2004;54:794–8. 7. Metha M. Broken needle complicating spinal anaesthesia. Int J Obstet Anesth 2007;16:94–5.
8. Brown DL. Spinal, epidural and caudal anaesthesia. In: Miller RD editor. Anesthesia. 6th ed. Philadelphia: Churchill Livingstone; 2005. p. 1678. 9. Carvalho JCA. Ultrasound-facilitated epidurals and spinals in obstetrics. Anesth Clin 2008;26:145–58. 0959-289X/$ - see front matter
c 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ijoa.2013.08.006
Intraoperative hyperthermia during cesarean section: a pertinent lesson On a mission trip to a developing county, one of us (VF) managed a patient who developed intraoperative hyperthermia. She was a healthy 18-year-old nulliparous woman who underwent an emergency cesarean section under general anesthesia for fetal distress. Her preoperative examination was normal, malaria screening was negative and she was initially afebrile. She denied any previous abnormal reactions to anesthesia by herself or any family members. A routine rapid-sequence induction with thiopental 400 mg and succinylcholine 100 mg was used. A healthy child was delivered within 3 min. Oxytocin 5 IU was injected intravenously after the placenta was removed and an infusion of 20 IU in saline 500 mL was commenced. Anesthesia was maintained with 70% nitrous oxide in oxygen and halothane 0.6 vol%; atracurium 12.5 mg and meperidine 100 mg were given. Twenty minutes later, the axillary temperature rose to 39.0°C, and subsequently as high as 40.5°C. Penicillin 1 g was given intravenously. Her blood pressure remained stable at 110/70 mmHg but she had a persistent tachycardia of 120–130 beats/min. No muscle rigidity was noticed. A capnograph was not available. Surgery was completed in 70 min. After antagonism of residual neuromuscular block, spontaneous breathing resumed but she remained unconscious with stable vital signs except for tachycardia and pyrexia. Differential diagnosis of malignant hyperthermia was considered but the local anesthetic technician suggested malaria despite negative preoperative screening. Since dantrolene was not readily available, quinine 600 mg in 5% glucose 500 mL was given intravenously. Blood glucose concentration was checked hourly since it can be decreased by quinine.1 In the recovery room, cooling the patient with cold intravenous fluids and blankets soaked in cold water had little effect. Within 3 h of starting quinine her temperature decreased to 38°C and she regained consciousness. She was extubated in the recovery room and was transferred to the intensive care unit for one night. Subsequently, the laboratory confirmed the patient as having Plasmodium vivax malaria. She was discharged from the hospital with a healthy baby on day five.
