Case 41: Intraoperative Epidural Catheter Malfunction
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A 62-year-old obese male (wt, 120 kg; ht., 190 cm; body mass index, 33.2 kg/m2), ASA 2, is scheduled for a colectomy secondary to ulcerative colitis. You plan a combined general anesthetic technique with an epidural. When the patient is in the operating room, you place an epidural catheter (20 G closed tip) (B. Braun Medical Inc., Bethlehem, PA 18018, USA) uneventfully in the L4–L5 interspace. The length of the epidural catheter in the epidural space is 4 cm. As is your practice, the epidural catheter, as it leaves the patient’s back, is led in a semicircle over a folded 2 × 2 inch swab. This is then covered with an OpSite (Flexigrid, Smith and Nephew, Hull HU3 2BN, England). The catheter is attached to the patient’s back and over his right shoulder using Compound Benzoin Tincture USP (The Clinipad Corporation, Guilford, CT 06437, USA) and tape (Hytape Surgical Produce Corporation, Yonkers, NY 10704, USA). There is a negative test to 3 ml of lidocaine 2% with epinephrine 1; 200,000. A total of 22 ml of lidocaine 2% is then injected and a block to T-4 is achieved. The patient is placed in a supine position and routine general anesthesia commenced. Further two additional boluses are injected into the epidural space with good effect and no problem. Forty minutes after the last dose, the surgeon requests that the patient be placed in a steep head-down position. Shortly thereafter, it becomes impossible to inject anything through the epidural catheter, despite the use of a small syringe. You suggest that the surgeon puts the table back in the original position, but he is unwilling to do so at that time. You are reluctant to abandon your epidural. Is there anything else you could do to get the epidural to function adequately again?
KeywordsEpidural catheter Obesity General anesthesia Epidural Subcutaneous tissue
- 4.Wildsmith JAW, Armitage EN. Principles and practice of regional anesthesia. 2nd ed. New York: Churchill Livingstone; 1993.Google Scholar