Letters to the Editor: Letters & Announcements
To the Editor:
Thoracic epidural analgesia is commonly used to provide perioperative analgesia in patients undergoing thoracic surgery, and pleural puncture by the needle or the catheter is an uncommon and a life-threatening complication (1–4).
A 67-year-old female patient, body mass index 36 kg/m2 (weight, 105 kg; height, 170 cm) was scheduled for lobectomy. The awake patient was placed in the left lateral decubitus position. An 18-gauge Tuohy needle was inserted at the T6–7 interspace with a midline approach. Technical difficulties were encountered because of poor body landmarks and decreased resistance of the deeper tissue levels. On the fourth attempt, a loss of resistance to saline was detected, and the epidural catheter was threaded easily. No chest symptoms were observed. Ten milliliters of 0.25% bupivacaine and 100 μg fentanyl were injected from the catheter. Unfortunately, there was not enough time to assess the level of sensory block before the induction. When the chest cavity was entered, the epidural catheter was found penetrating the parietal pleura in close proximity to both the spine and the thoracic aorta (Fig. 1). There was no obvious bleeding or injury to the lung. The catheter was withdrawn and the postoperative course was uncomplicated.
Only few cases about the misplacement of the thoracic catheter into the pleural cavity have been reported in the literature (1–4). In most of these case reports, the paramedian approach was used during needle insertion (1–4). Our case report is the only one in which the midline approach was used. The paramedian approach to the thoracic epidural space is thought to have fewer potential technical problems but a higher complication rate; therefore, it is believed that the use of the midline approach may minimize the risk (2). However our case report showed that the midline approach is not free from complications. Sprung et al. (5) investigated the factors that may predict the difficulty of performing neuraxial blocks and concluded that the quality of body landmarks was the most significant independent predictor of difficulty and the obese patients had the highest incidence of having poor landmarks.
In conclusion, in obese patients with poor body landmarks, the sensory level of analgesia should be assessed preoperatively or the correct placement of the catheter should be verified by radiography to decrease the incidence of technique-related complications during epidural analgesia.
Zeynep Eti, MD *
Tunç Laçin, MD †
Bedrettin Yıldızeli, MD †
Varlık Dogan, MD *
F. Yılmaz Gögüs, MD *
Mustafa Yüksel, MD †
*Departments of Anesthesiology and †Thoracic Surgery; Medical Faculty of Marmara University; Istanbul, Turkey; email@example.com
1. Furuya A, Takashi M, Ozaki M, Kumazawa T. Interpleural misplacement of an epidural catheter. J Clin Anesth 1998;10:425–6.
2. Patt RB, Reddy S, Wu CL, Catania JA. Pneumothorax as a consequence of thoracic subarachnoid block. Anesth Analg 1994;78:160–2.
3. Grieve PP, Whitta RKS. Pleural puncture: an unusual complication of a thoracic epidural. Anesth Intensive Care 2004;32:113–6.
4. Koch J, Nielsen JU. Rare misplacements of epidural catheters. Anesthesiology 1986;65:556–7.
5. Sprung J, Bourke DL, Grass J, et al. Predicting the difficult neuraxial block: a prospective study. Anesth Analg 1999;89:384–9.