The unexpected epidural: a case report

BMC Anesthesiology

Riccardo Pinciroli¹  Roberto Fumagalli¹ 

[1] Department of Health Sciences, University of Milan-Bicocca, Monza, Italy

关键词: Complications;    Fragment;    Catheter;    Epidural;    Retained;    Breakage;   

Others  :  1212226
DOI  :  10.1186/s12871-015-0062-4

 received in 2014-10-22, accepted in 2015-05-22,  发布年份 2015

【 摘 要 】

Background

We report the peculiar case of a patient with a retained large epidural catheter fragment, incidentally found 12 years after its placement. Our primary aim is to emphasize how the breakage and retention of even exceptionally large portions of this device can go undetected. The patient can be completely asymptomatic and, with no clue that such a foreign body exists, the presentation of its potential complications can be subtle and misleading. To our knowledge, this is the first reported case of the incidental discovery of such a large fragment so many years after its placement. No consensus exists about how to handle this complication, therefore our report adds to the amount of available evidence.

Case Presentation

A 53-year-old caucasian female with a history of diverticulitis requiring multiple hospitalizations underwent laparoscopic sigmoidectomy. The early postoperative period was complicated by peritonitis, demanding an urgent “second-look” exploratory laparoscopy. Nine days post-operatively, a filiform metallic object in the upper-quadrant was noted on x-ray. No epidural had been placed for either one of her recent surgeries. Given the patient’s history, the object was initially thought to be a retained surgical sponge. Previous studies, however, showed that the same image was already present preoperatively. Upon further questioning, the patient reported an epidural being placed twelve years before, at the time of her pregnancy. No mention of breakage had been made to her at that time, nor a retained foreign body was ever reported afterwards, despite her many imaging exams. She also never experienced any symptoms. A 15 cm fragment of a wire-reinforced catheter was surgically retrieved under local anesthesia and fluoroscopic guidance.

Conclusion

Breakage of the epidural catheter with fragment retention is a known complication of this device, possibly leading to devastating sequelae. The fragment can go undetected for years. In this case our finding was incidental and the patient was asymptomatic. However, in the event a neurologic complication arose, the identification of the unknowingly retained epidural as the causative agent could have been difficult and delayed, with potential harm to the patient.

【 授权许可】

   
2015 Pinciroli and Fumagalli.

【 图 表 】

Fig. 1.

Fig. 2.

【 参考文献 】

• [1]Moen V, Dahlgren N, Irestedt L. Severe neurological complications after central neuraxial blockades in Sweden 1990–1999. Anesthesiology. 2004; 101:950-9.
• [2]Tio TO, Macmurdo SD, McKenzie R. Mishap with an epidural catheter. Anesthesiology. 1979; 50:260-2.
• [3]Fischer R. Epidural conduction device fractures and complications of retained fragments. AANA J. 2008; 76:37-40.
• [4]Scott EM, Scott BB. Painful rib syndrome–a review of 76 cases. Gut. 1993; 34:1006-8.
• [5]Mitra R, Fleischmann K. Management of the sheared epidural catheter: is surgical extraction really necessary? J Clin Anesth. 2007; 19:310-4.
• [6]Morris GN, Warren BB, Hanson EW. Influence of patient position on withdrawal forces during removal of lumbar extradural catheters. Br J Anaesth. 1996; 77:419-20.
• [7]Hobaika AB. Breakage of epidural catheters: etiology, prevention, and management. Rev Bras Anestesiol. 2008; 58:227-33.
• [8]Boey SK, Carrie LE. Withdrawal forces during removal of lumbar extradural catheters. Br J Anaesth. 1994; 73:833-5.
• [9]Pierre H, Block B, Wu C. Difficult removal of a wire-reinforced epidural catheter. J Clin Anesth. 2003; 15:140-1.
• [10]Sia-Kho E, Kudlak TT. How to dislodge a severely trapped epidural catheter. Anesth Analg. 1992; 74:933.
• [11]Gadalla F. Removal of a tenacious epidural catheter. Anesth Analg. 1992; 75:1071-2.
• [12]Jongleux EF, Miller R, Freeman A. An entrapped epidural catheter in a postpartum patient. Reg Anesth Pain Med. 1998; 23:615-7.
• [13]Lee YH, Hwang HY, Sim WS. Breakage of a thoracic epidural catheter during its removal-A case report. Korean J Anesthesiol. 2010;  58:569-72.
• [14]Armendi AJ, Ryan JF, Chang HM. Retained caudal catheter in a paediatric patient. Pediatr Anesth. 1992; 2:325-7.
• [15]Collier C. Epidural catheter breakage: a possible mechanism. Int J Obstet Anesth. 2000; 9:87-93.
• [16]Drew T, Vo ML, Wolfe JM. The invisible gorilla strikes again: sustained inattentional blindness in expert observers. Psychol Sci. 2013; 24:1848-53.
• [17]Renehan EM, Peterson RA, Penning JP. Visualization of a looped and knotted epidural catheter with a guidewire. Can J Anesth/J Can Anesth. 2000; 47:329-33.
• [18]Asai T, Yamamoto K, Hirose T, Taguchi H. Breakage of epidural catheters: a comparison of an arrow reinforced catheter and other nonreinforced catheters. Anesth Analg. 2001; 92:246-8.
• [19]Sawyer-Glover AM, Shellock FG. Pre-MRI procedure screening: recommendations and safety considerations for biomedical implants and devices. J Magn Reson Imaging. 2000; 12:510.