Accidental catheterization of epidural venous plexus : tomographic analysis

Revista Brasileira de Anestesiologia

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REFERÊNCIA

0OUZA, Mariano Paiva et al Accidental catheterization of epidural venous plextus tomographic

analysis Revista Brasileira de Anestesiologia, Campinas, v 66, n 2, p 208-211, mar /abr 2016

Disponível em <http //www scielo br/scielo

phpscscriptssci_aarttexttppids00034--7094-2016000200208plngsenpnrmsiso> Acesso em 16 mar 2018 doi

http //dxt doi org/10 1016/. b.ane 2013 03 022

REVISTA

BRASILEIRA

DE

ANESTESIOLOGIA

www.sba.com.br

CLINICAL

INFORMATION

Accidental

catheterization

of

epidural

venous

plexus:

tomographic

analysis

夽

Mariano

Paiva

Souza

_,

_Edno

_Magalhães

_,

_Elialba

_de

_Farias

_Cascudo

_,

Marco

Antonio

Dias

Jogaib

,

Marcelo

Carneiro

da

Silva

a_{HospitalRegionaldoGama(HRG),Brasília,DF,Brazil} b_{UniversidadedeBrasília(UnB),Brasília,DF,Brazil}

c_{ScientificDepartment,SociedadeBrasileiradeAnestesiologia,Brasília,DF,Brazil}

Received12June2012;accepted20March2013 Availableonline31March2014

KEYWORDS Complications: venous catheterization; Anesthesia:epidural anesthesia; Epiduralcatheter; Tomography:venous plexus; Intervertebralvein; Azygosvein Abstract

Backgroundandobjectives: Inadvertentvenouscatheterizationsoccurinapproximately9%of

lumbarepiduralanestheticprocedureswithcatheterplacementand,if notpromptly

recog-nized,canresultinfatalconsequences.Theobjectiveofthisreportistodescribeacaseof accidentalcatheterizationofepiduralvenousplexusanditsrecordingbycomputedtomography withcontrastinjectionthroughthecatheter.

Casereport: Afemalepatientinhersixties,physicalstatusII(ASA),underwentconventional cholecystectomyunderbalancedgeneralanesthesiaandanepiduralwithcatheterfor postop-erativeanalgesia.Duringsurgery,therewasclinicalsuspicionofaccidentalcatheterizationof epiduralvenousplexusbecauseofbloodbackflowthroughthecatheter,confirmedbythe admin-istrationofatestdosethroughthecatheter.Afterthesurgery,aCTscanwasobtainedafter contrastinjectionthroughthecatheter.Contrastwasobservedallthewayfromtheskintothe azygosvein,passingthroughanteriorandposteriorepiduralvenousplexusesandintervertebral vein.

Conclusion:Itispossibletoidentify theactualplacement oftheepiduralcatheter,aswell

asto registeran accidentalcatheterization of theepidural venousplexus, usingcomputed

tomographywithcontrastinjectionthroughtheepiduralcatheter.

©2014SociedadeBrasileiradeAnestesiologia.PublishedbyElsevier EditoraLtda.Allrights reserved.

夽 _{StudyconductedattheHospitalRegionaldoGama(HRG),Brasília,DF,Brazil.} ∗_{Correspondingauthor.}

E-mails:dr-marianosouza@gmail.com,dr-marianosouza@hotmail.com(M.P.Souza).

0104-0014/$–seefrontmatter©2014SociedadeBrasileiradeAnestesiologia.PublishedbyElsevierEditoraLtda.Allrightsreserved. http://dx.doi.org/10.1016/j.bjane.2013.03.022

Accidentalcatheterizationofepiduralvenousplexus:tomographicanalysis 209

PALAVRAS-CHAVE Complicac¸ões: cateterizac¸ãovenosa; Anestesia:peridural; Cateterperidural; Tomografia:plexo venoso; Veiaintervertebral; Veiaázigo

Cateterizac¸ãoacidentaldoplexovenosoperidural:análisetomográfica

Resumo

Justificativaeobjetivos: Acateterizac¸ãovenosainadvertidaocorreemaproximadamente9%

dasanestesias periduraislombarescomintroduc¸ãodecateterecasonão seja prontamente

reconhecidapodetrazerconsequênciasfatais.Oobjetivodesterelatoédescreverumcasode cateterizac¸ãoacidentaldoplexovenosoperiduraleoseuregistroportomografia computa-dorizadacominjec¸ãodecontrastepelocateter.

Relatodecaso: Pacientefeminina,sexagenária, estadofísico II(ASA), submetida à colecis-tectomiaconvencionalsobanestesiageralbalanceadaeperiduralcomcateterparaanalgesia pós-operatória.Durantecirurgiahouvesuspeic¸ãoclínicadecateterizac¸ãoacidentaldoplexo venosoperidural,porrefluxodesanguepelocateter,fatoconfirmadopela administrac¸ãode

dose-teste pelo cateter. Feita tomografia computadorizada com injec¸ão de contraste pelo

cateter,apósoterminodacirurgia.Observadotodootrajetodocontrastedesdeapeleatéa veiaázigo,passandopeloplexovenosoperiduralanterior,posterioreveiaintervertebral.

Conclusão:Épossívelaidentificac¸ãodorealposicionamentodocateterperidural,bemcomo oregistrodacateterizac¸ãoacidentaldoplexovenosoperidural,pormeiodetomografia com-putadorizadacominjec¸ãodecontrastepelocateterperidural.

©2014SociedadeBrasileira deAnestesiologia.PublicadoporElsevierEditoraLtda.Todosos direitosreservados.

Introduction

Inadvertentvenouscatheterizationoccursinapproximately 9%oflumbarepiduralanestheticprocedureswithcatheter placement1 _{and ifnot promptly recognized,can resultin} fatalconsequences,suchasconvulsions,cardiotoxicityand cardiovascularcollapse.1,2

The objective of this report is to describe a case of accidentalcatheterizationoftheposteriorepiduralvenous plexusanditsdocumentationbycomputedtomographywith injectionofiodinatednon-ioniccontrastthroughthe epidu-ralcatheter.

Case

report

A female patient, 63 years old, physical status II (ASA); underwent conventional cholecystectomy under balanced generalanesthesiaandanepidural.Initiallyconscious seda-tionwasapplied,withthepatientproperlymonitoredwith pulseoximetry,continuousECGandnoninvasiveblood pres-sure.Intheleftlateraldecubitusposition,punctureofthe epidural space between T11 and T12 was taken, with a positiveloss ofresistancetest andnegativeaspirationfor CSFor blood,usinga16GTuohyneedlewithitsbevelina cephaladorientation.Afterthepuncture,3mLof2% lido-caine with epinephrine was administered (test dose). No change in heart rate or electrocardiographic tracing was observed, so 20mL of 0.5% ropivacaine was applied, and amulti-fenestrated 16Gepiduralcatheterwasintroduced forthepurposeofpostoperativeanalgesia.Afterthis pro-cedure, suction was done, when reflux of fluid with a small amount of blood was observed. After securing the catheterto the skin and withthe patientin the horizon-taldorsaldecubitumposition,balancedgeneralanesthesia withpropofol,fentanylandsevofluranewasperformed.The

surgicalprocedurewasuneventful.Attheendofthesurgery anewaspirationthroughthecatheterwasperformed,when blood reflux wasagain observed. Then, 3mL of lidocaine withadrenalinewasadministeredthroughthecatheterand subsequentlya40%increaseinheartratewasnoted.After the surgery, the patient, already extubated and in spon-taneous breathing, lucid and oriented was taken to the radiologydepartment.Ahelicalcomputedtomographyscan wasperformedwithinjectionof4mLofiodinatednon-ionic contrastthroughtheepiduralcatheter.The imageanalysis revealed the catheterpath from the skin to theepidural space(Fig.1). This procedure allowed theobservation of theposteriorandanteriorinternalepiduralvenousplexuses (Fig. 2). The intervertebral vein was also identified from its origin in the intervertebral foramen to its confluence withtheazygosvein(Fig.3).Inimagesintheaxial,sagittal andcoronalplanes,itispossibletoidentifytheazygosvein throughoutitsabdominalandthoracicportion(Figs.4---6).

Thecatheterwasremoveduneventfully.Thepatienthad a good clinical course and was discharged on the second postoperativeday,withnocomplaints.

Figure1 Cathetercontrastedfromtheskintotheepidural space,markedbyredarrows.

Figure2 Anteriorandposteriorepiduralvenousplexuswith contrast.

Figure3 Intervertebralvein.

Discussion

Thecatheterizationoftheinternalepiduralvenousplexus isapossiblecomplication,evenwhentheoperatorfollows thepropertechnique.Severalstudieshavetriedtocorrelate strategiesassociatedwithalowerincidenceofinadvertent catheterizationoftheepiduralvenousplexus.3_Mhyreetal., inameta-analysisinvolving30clinicaltrialsandmorethan 12,000patients, concludedthat therisk of venous plexus catheterizationcanbereduced,ifthefollowingstrategies are applied: positioning the patient in lateral decubitus,

Figure4 Azygosveinintheaxialplane.

Figure5 Azygosveininthesagittalplane.

fluidpre-distension,useofsingle-holecathetersandlimiting thedepthofcatheterinsertionto6cmorless.1

Given the relative frequency of accidental epidural venous plexus catheterizationsandthe direconsequences thatanaccidentalintravascularinjectionoflocalanesthetic cancause,itisimperativefortheimmediaterecognitionof thiscomplication bythe anesthesiologist.The administra-tionofatestdose throughthecathetermustbearoutine maneuver, evenwhen the test dose by needle was nega-tive.Whileitispossibletodocumenttheactualplacement of the epidural catheter,aswell as the occurrenceof an

Accidentalcatheterizationofepiduralvenousplexus:tomographicanalysis 211 accidental venous catheterization using computed

tomo-graphy with contrast injection through the catheter, its occurrencemust be clinicallyrecognized,sincethe imag-ingtestisnotaccessibletotheanesthesiologistinhis/her dailypractice,becauseof itshigh costorthedifficultyof conductingthispatienttotheradiologydepartmentpre-or perioperatively.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

References

1.MhyreJM,GreenfieldMLVH,TsenLC,PollyL.Asystematicreview ofrandomizedcontrolledtrialsthatevaluatestrategiestoavoid epidural vein cannulation during obstretric epidural catheter placement.ObstetrAnesthesiol.2009;108:1232---42.

2.RodgersA, WalkerN,Schug S,et al. Reductionof postopera-tivemortalityandmorbiditywithepiduralorspinalanaesthesia: resultsfromoverviewofrandomizedtrials.BMJ.2000;321:1493. 3.Hogan Q. Epidural catheter tip position and distribution of injectate evaluatedbycomputed tomography. Anesthesiology. 1999;90:964---70.