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1 広島大学学術情報リポジトリ Hiroshima University Institutional Repository Title Auther(s) Citation Issue Date Atypical Rapid Onset of Lumbar Epidural Anesthesia after Confirming Negative Results of a Test Dose Yamaguchi, Satoshi; Kitamura, Jiro Ansesthesia and Resuscitation, 52 (4) : DOI Self DOI URL Right Relation

2 麻酔と蘇生第52巻第 4 号平成28年12月20日発行昭和47年 4 月19日第 4 種学術刊行物認可広島麻酔医学会発行略名麻と蘇Anesth Resus ISSN 国際標準逐次刊行物番号麻と酔蘇生 Anesthesia and Resuscitation 第五十二巻麻酔と蘇生 Anesthesia and Resuscitation Volume 52 Number 4 December 2016 第四号目次紹介看護師に対する術後鎮痛に関する意識調査 PCA 導入に向けての現状と課題三浦亜里彩他 109 通巻第一九八平成二十八年十二月第51回山陰麻酔学会抄録集 115 English Article CASE REPORT Atypical Rapid Onset of Lumbar Epidural Anesthesia after Confirming Negative Results of a Test Dose Satoshi YAMAGUCHI, et al 119 Migration of a Correctly Positioned Tip of a Central Venous Catheter from the Superior Vena Cava to the Left Subclavian Vein within a Short Time Shiro FUKUDA, et al 123

3 AnesthesiaandResuscitation(December20,2016) Volume52,No.4 119~ 121 AtypicalRapidOnsetofLumbarEpiduralAnesthesiaafter ConfirmingNegativeResultsofaTestDose SatoshiYAMAGUCHI* 1 andjirokitamura* 1 Introduction Testdoseinjectioninepiduralanesthesiaistypicaly performed toruleoutmisplacementoftheepidural catheterorneedle. Here,wereportacaseofrapidonsetoflumbarepidural anesthesiaimmediatelyafterinjectingamaindose,while confirmingnoaspirationofcerebrospinalfluidorblood, andnomotororsensoryblockadefolowinginjectionofa testdose. Casereport Thepatientwasa75-year-oldwoman(height,145cm; weight,48kg)undergoingsurgicalrepairofaleftinguinal herniawithlumbarepiduralanesthesia. Shedidnot complainofanyneurologicalsymptomsafectingthelower limbsandhadnopriorhistoryoflumbarsurgery,external injuries,orneuraxialblockade. Findingsofapreoperative physicalexaminationwerenormal. LumbarpuncturewasperformedattheL1 L2interspace byusinga1-cm-lateralparamedianapproachwithan18- gauge Tuohy needle in the rightlateraldecubitus position. Lossofresistancetosalineinjectionwasusedto identifytheepiduralspace,whichwasatadepthof5.5 cm. Asingle-orifice,open-ended,epiduralcatheterwas inserted 3cm beyond the needle tip. The above procedurewassuccessfulyperformedoncewithoutany complicationorcomplaintofseverepainornumbness. After confirmation of no aspiration of blood or cerebrospinalfluid,3mlof2%lidocainewasinjectedasa testdose. After3min,noevidenceofsensoryormotor blockadeofthelowerlimbswasobserved. Consequently, 7mlof2%lidocainewasinjectedasamaindosethrough theepiduralcatheterover30s. Immediatelyafterthe injection,bromagescale1motorblockadeandl1sensory blockadewereobserved. Twentysecondslater,motor blockadeprogressedtobromagescale3andsensory blockadealsorosetothelevelofth2. Thepatient complainedofdysarthria,dyspnea,andnumbnessofboth upperlimbs. Subsequently,heroxygensaturation(SpO 2 ) * 1 DepartmentofAnesthesia,TokatsuHospital,Nagareyama,Japan leveldecreased from 98% to88%. Inhalation of100% oxygenat10l/minwasadministeredandspo 2 levels recoveredto98%. However,thepatientbecameunableto vocalizeandsubsequentlylostconsciousness. Asthe patient srespiratoryconditionremainedstable,herability tobreathenaturalywasobserved. Furtheratemptswere madetoaspiratetheepiduralcatheter,butitwasnotable todrawfluidorblood. Subsequently,herbloodpressure decreasedfrom 125/77to68/35mmHgandherheart ratedecreasedfrom 72to45beats/min. Consequently, ephedrine (8 mg) and atropine (0.5 mg) were administered,whichresultedinrecoveryofbloodpressure and heartrate to101/56mmhg and65beats/min, respectively. Folowingthis,herhemodynamicsremained stableandthesurgerywasperformedasscheduled. Thesurgicalprocedurewasuneventfulwithaduration of70min. Wefrequentlytriedtoaspiratethecatheter intraoperativelybutwereunabletodrawfluid. Postoperatively,thepatientawokenaturalyandhervital signsremainedstable. Sinceshewasabletobreathe withoutcomplainingofdyspnea,shewastransferredtothe surgicalward. Atthattime,theepiduralcatheterwas removedandnoleakageoffluidfrom thepuncturesite wasobserved. At160minaftertheepiduralinjection,thepatient completely recovered from sensory and motor blockade. Magneticresonanceimagingofthespine showedonlyslightspinalstenosisatthel3 L4level. The postoperativecoursewasuncomplicatedandthepatient wasdischargedonfootonpostoperativeday4. Discussion Ithasbeencustomaryinourinstitutiontoinject3mlof 2%lidocaine(60mgoflidocaine)asatestdoseafter insertionofacatheterintotheepiduralspacetoruleout misplacement. Then,3min afterward,the patient s conditionisevaluatedaccordingtobromagescaleasa diagnostictest,becausetheonsetofneuralblockade with3mlof2% lidocaineviaintrathecalinjection is withinapproximately3min. 1) Thusfar,wehavenever encounteredacaseofrapidonsetofepiduralanesthesia, aswiththiscase. 119

4 Yamaguchietal:RapidOnsetofEpiduralAnesthesia Colonna-Romanoetal. 2) reportedthediagnosticaccuracy ofanintrathecaltestdoseof45mgoflidocainewith0.015 mg ofepinephrineinepiduralanesthesiaasfolows: sensitivityandspecificityof100%[95%confidenceinterval (CI)=78% 100%]and93%(95%CI=66% 100%),respectively, andnegativeandpositivepredictivevaluesof100%and25% (assuming a2% prevalenceofan intentionalspinal), respectively,by the ability to raise the legsasan indicator. Ingeneral,adiagnostictestwithasensitivityof morethan80%isconsideredefective 3) andindicatesthat thevalidityofatestdoseinepiduralanesthesiahasbeen suficientlyconfirmed. Severalstudies 4,5) havereportedthattheintervalfrom injectionofatestdosetoevaluatethesignsofneural blockadeisapproximatelywithin3min,aswiththepresent case. However,Colonna-Romanoetal. 2) concludedthat4 minisneededtorecognizethesignsofmisplacementofan epiduralcatheter. Althoughthispatientwasofsmal stature(height,145cm),therewasapossibilitythatneural blockadewasevaluatedtooquickly. Furthermore,the testdoseinjectedintotheepiduralspacemayalsohave beenmuchmorethanneeded. Forthesereasons,the rapidonsetofneuralblockademayhavebeenanefectof thetestdoseorsynergism withmaindose. Iftheefectof thetestdosehadbeenevaluated4 5minafterinjection,it mayhavebeenpossibletoanticipatethepossibilityof rapidneuralblockadeonset. Hence,wehaverevisedthe intervaltimefrom injectionofatestdosetoevaluatethe signsofneuralblockade from 3min to5min,and amendedthetestdoseoflidocainefrom 60mgto45 mg. Furthermore,itisalsoimportanttoadministeran anestheticinmultiplesmalerdosesoveralongerperiodof timeandfrequentlyconfirm thelevelsofblockadein epiduralanesthesia. Inthepresentcase,theepiduralcatheterwasremoved afterthe operation. And,we could notconfirm its misplacementonaradiographicimage. Therefore,based ontheclinicalfindings,subarachnoidinjectionorsubdural injectionwasconsideredtobethecauseoftheatypical rapid onsetofneuralblockade. Itwasnotpossible toaspiratecerebrospinalfluiddespitehavingmultiple atemptsinthiscase. However,eventhoughcerebrospinal fluidcouldnotbeaspirated,thereisnoguaranteethatno localanestheticwasdelivered into thesubarachnoid space. 6) Forasubduralblock,thesymptomswilvary accordingtothecathetertiplocation. 3) Therefore,theuse ofaconventionaltestdosemayfailtorevealsubdural cathetermisplacement. In thiscase,weused asingle-orifice,open-ended, epiduralcatheter. Amulti-orifice,close-ended,catheter, whichisanotherepiduralcathetertype,iseasierandless painfultoplace,andmakessensoryblockadetobemore exact. However,ithasthe risk ofhazardousdual compartmentalmisplacement. 7) Occasionaly,adistal openingofcathetermayliewithinthesubarachnoidor subduralspace,whileaproximalorificesimultaneously retainsnormalaccesstotheepiduralspace. Usingsuch improperlyplacedcathetercancausenotonlyatypical blockadebutalsosecondaryduralinjury. Thinkingofthe malpositioningofepiduralcatheter,itmaybebetertouse asingle-orificetypecatheter. Theincidencesofsubarachnoidandsubduralinjection arereportedly0.5% 2.0% 2,8) and0.8% 1.0%, 9) respectively. However,evenwhenepiduralblockadeisperformedby trainedanesthesiologists,theneedlecanpartlypierce theduramateratanincidenceofupto7%. 3) These complicationsmayoccurmorefrequentlythangeneraly considered. Inconclusion,atypicalrapidonsetofepiduralanesthesia mayoccur,evenafterconfirmingnegativeresultsofthe testdoseandaspirationtest. Thefindingspresentedare from asinglecasereport,andthus,furtherstudiesare requiredtoverifythesefindings. Consent Writeninformedconsentwasobtainedfrom thepatient forpublicationofthiscasereport. References 1)WulfH,HamplK,SteinfeldtT:Speedspinalanesthesia revisited:new drugsandtheirclinicalefects. CurrOpin Anaesthesiol,26: ,2013 2)Colonna-RomanoP,PadolinaR,LingarajuN,etal:Diagnostic accuracyofanintrathecaltestdoseinepiduralanalgesia. Can JAnaesth,41: ,1994 3)GuayJ:Theepiduraltestdose:areview. AnesthAnalg,102: ,2006 4)MooreDC,BatraMS:Avoidingsubarachnoidorintravascular injection of local anesthetics: a single test dose. Anesthesiology,117: ,2012 5)PratS,VasudevanA,HessP:Aprospectiverandomizedtrial oflidocaine30mgversus45mgforepiduraltestdosefor intrathecalinjectionintheobstetricpopulation. Anesth Analg,116: ,2013 6)TsuiBC,GuptaS,FinucaneB:Detectionofsubarachnoidand intravascularepiduralcatheterplacement. CanJAnaesth,46: ,1999 7)BeckH,BrassowF,DoehnM,etal:Epiduralcathetersofthe multi-orifice type: dangers and complications. Acta AnaesthesiolScand,30: ,1986 8)Bonica J,BackupPH,AndersonCE,etal:Periduralblock:an 120

5 Yamaguchietal:RapidOnsetofEpiduralAnesthesia analysisof3,637casesandareview. Anesthesiology,18: ,1957 9)LubenowT,Keh-WongE,KristofK,etal:Inadvertentsubdural injection:acomplicationofanepiduralblock. AnesthAnalg, 67: ,1988 AcceptedforPublication,July24,

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