Secondary Logo

Journal Logo

Epidural Anesthesia for Cesarean Delivery in a Parturient With Lumboperitoneal Shunt: A Case Report

Moreno-Duarte, Ingrid MD*; Hall, Robert R. III BS*; Shutran, Max S. MD; Radhakrishnan, Manga G. MD*; Drzymalski, Dan M. MD*

doi: 10.1213/XAA.0000000000000960
Case Reports
Free

A lumboperitoneal shunt facilitates dynamic flow of cerebrospinal fluid into the peritoneum. Consequently, neuraxial technique placement in the parturient with a lumboperitoneal shunt can result in unexpected levels of blockade. We present the case of a parturient with a lumboperitoneal shunt who experienced symptoms consistent with high blockade after epidural administration of 450 mg chloroprocaine. This report emphasizes potential mechanisms for high neuraxial blockade and strategies to decrease risks in this unique patient population.

From the Department of *Anesthesiology and Critical Care

Neurosurgery, Tufts Medical Center, Boston, Massachusetts.

Accepted for publication December 6, 2018.

Funding: None.

The authors declare no conflicts of interest.

Address correspondence to Robert R. Hall III, BS, Departments of Anesthesiology and Critical Care, Tufts Medical Center, 800 Washington St, Ziskind 6, Boston, MA 02111. Address e-mail to rhall1@tuftsmedicalcenter.org.

The lumboperitoneal shunt is a technique that can be performed in patients requiring diversion of cerebrospinal fluid (CSF).1,2 The presence of a lumboperitoneal shunt can change the fluid dynamics of the CSF, which has implications for anesthesiologists who encounter parturients with indwelling lumboperitoneal shunt in whom neuraxial anesthesia is desired.1 Although spinal and epidural techniques have been safely placed in certain cases, patients are at a higher risk for complications after lumboperitoneal shunt placement.3 We present the case of a parturient with lumboperitoneal shunt who experienced upper extremity weakness and shortness of breath shortly after administration of local anesthetic via epidural catheter. A written informed consent was obtained from this patient with permission to publish the following report.

Back to Top | Article Outline

CASE REPORT

A 26-year-old woman, gravida 3, para 2 at 37 weeks’ gestation was admitted to the labor and delivery unit for repeat cesarean delivery in the setting of premature rupture of membranes. She was 147 cm tall, weighed 88 kg, and had a body mass index of 40.9 kg/m2. Her medical history was significant for pseudotumor cerebri treated with an indwelling lumboperitoneal shunt at the L2–L3 interspace, as well as 2 prior cesarean deliveries. The patient also reported difficult spinal technique placement with prior deliveries and a history of postdural puncture headache treated with blood patch.

After discussion with her neurosurgeon, the decision was made to perform a combined spinal–epidural technique below the level of the lumboperitoneal shunt to decrease the risk of lumboperitoneal shunt damage. The L4–L5 intervertebral space was identified by landmark technique, and a 17-gauge Tuohy needle was inserted to find the epidural space. After 4 attempts, loss of resistance was encountered at 9 cm. A 25-gauge Pencan needle was passed through the Tuohy needle but failed to yield flow of CSF. The epidural catheter was threaded through the Tuohy needle and affixed at 14 cm.

After it was confirmed that aspiration through the epidural catheter did not yield any fluid, 3 mL of 1.5% lidocaine with 15 µg epinephrine was administered via the epidural catheter. The patient’s pulse and blood pressure were similar before and after administration of the lidocaine. Subsequently, 15 mL of 3% chloroprocaine in 5-mL increments was administered every 2 minutes until a T4 sensory block was obtained, but soon afterward the patient reported shortness of breath and an inability to move her upper extremities. Grip strength was found to be decreased bilaterally, the patient’s pulse was 84 beats per minute, and the blood pressure was 119/65 mm Hg.

The patient’s clinical status remained unchanged for several minutes, so the case proceeded. After delivery of a healthy neonate with Apgar scores of 6 and 9 at 1 and 5 minutes, respectively, tubal ligation was performed. Thirty minutes after the initial administration of chloroprocaine, the patient reported recovery of motor function in her upper extremities and improved respiratory status. For the remainder of the 2.5-h–long procedure, further administration of local anesthesia was not required. The patient was taken to the recovery room at the end of surgery and regained motor and sensory function in her lower extremities. During the rest of her hospital stay, there was no evidence of postdural puncture headache. She was discharged on postoperative day 5.

Back to Top | Article Outline

DISCUSSION

In this case report, we describe a parturient with an indwelling lumboperitoneal shunt who experienced symptoms consistent with high neuraxial blockade shortly after administration of local anesthetic for cesarean delivery. The purpose of this discussion is to establish the potential challenges and complications of placing neuraxial techniques and dosing those techniques in parturients with lumboperitoneal shunt.

The relation between lumboperitoneal shunt and a high spinal blockade following medication administration via epidural catheter can be explained by a potential communication between the epidural and intrathecal spaces. Lumboperitoneal shunt placement is performed by inserting an indwelling catheter of 2 mm diameter via a 14-gauge Tuohy needle into the intrathecal space, with the purpose of facilitating dynamic flow of CSF through the shunt into the peritoneum. While scarring eventually forms around the catheter, the administration of local anesthetic could increase pressure in the epidural space4–6 and open a communication between the intrathecal and epidural spaces. Should local anesthetic administered in the epidural space leak into the intrathecal space through that communication, the resultant block could have characteristics consistent with spinal blockade. This theory is supported by a prior report in which computed tomography demonstrated extravasation of contrast media from the intrathecal to epidural space in a patient with lumboperitoneal shunt.7

The possibility of high epidural blockade can be explained by the dosing of the epidural technique. While there was no maternal or fetal urgency for obtaining a surgical level, we chose to administer chloroprocaine to minimize the amount of additional time that the patient would have to wait in the setting of her multiple failed attempts. However, given that chloroprocaine has a very rapid onset of action,8 our approach of administering chloroprocaine in 5-mL increments every 2 minutes could have resulted in a higher epidural blockade. Had we administered chloroprocaine in <5 mL doses and waited longer between those doses, it is possible that we could have seen a T4 sensory block after the administration of <15 mL, which would have prompted us to stop administering additional local anesthetic.

Several strategies should be considered to minimize the chances of high spinal or epidural blockade. First, the duration of time between doses should be increased9 so that as soon as symptoms of an appropriate level of blockade occur, the provider can stop administering local anesthetic. Second, placement of the epidural catheter should occur above, instead of below, the level of lumboperitoneal shunt. Should an unexpected communication between the spinal and epidural spaces be present, less local anesthetic might be translocated through the lumboperitoneal shunt, because dosing local anesthetics in the lumbar epidural space results in greater cephalad, rather than caudal, spread. However, a higher-placed epidural catheter can result in higher epidural analgesia, making the approach to dosing of any catheter-based techniques critical. Finally, neuraxial ultrasound to evaluate the anatomic characteristics should be considered to guide placement and dosing of the neuraxial technique. However, not all providers of obstetric anesthesia have the experience necessary to perform and interpret neuraxial ultrasound.

The key learning point from this case report is that both the neuraxial technique and the dosing of those techniques may result in complications in parturients with lumboperitoneal shunt. Spinal and epidural anesthesia in parturients with lumboperitoneal shunt have been previously described,10–12 but the puncture of dura with a spinal needle may not always yield CSF.13,14 Furthermore, even if intrathecal injection of local anesthetic is possible, the anesthetic can fail due to leak of local anesthetic into the peritoneal cavity through the shunt.15 Catheter-based techniques may be preferred, but adhesions and scarring in the epidural space as a result of lumboperitoneal shunt placement could also change the distribution patterns of local anesthetic in the epidural space.11 Therefore, when providers encounter the parturient with lumboperitoneal shunt, it is very important to place and dose neuraxial techniques with the utmost care so as to avoid the risk of complications.

Back to Top | Article Outline

DISCLOSURES

Name: Ingrid Moreno-Duarte, MD.

Contribution:This author helped review the literature, and prepare and write the manuscript.

Name: Robert R. Hall III, BS.

Contribution:This author helped write and prepare the manuscript.

Name: Max S. Shutran, MD.

Contribution:This author helped review the literature and prepare the manuscript.

Name: Manga G. Radhakrishnan, MD.

Contribution:This author helped review the literature and prepare the manuscript.

Name: Dan M. Drzymalski, MD.

Contribution:This author helped review the literature, and prepare and write the manuscript.

This manuscript was handled by: BobbieJean Sweitzer, MD, FACP.

Back to Top | Article Outline

REFERENCES

1. Tang RA, Dorotheo EU, Schiffman JS, Bahrani HM. Medical and surgical management of idiopathic intracranial hypertension in pregnancy. Curr Neurol Neurosci Rep. 2004;4:398–409.
2. Brazis PW. Clinical review: the surgical treatment of idiopathic pseudotumour cerebri (idiopathic intracranial hypertension). Cephalalgia. 2008;28:1361–1373.
3. Palop R, Choed-Amphai E, Miller R. Epidural anesthesia for delivery complicated by benign intracranial hypertension. Anesthesiology. 1979;50:159–160.
4. Grocott HP, Mutch WA. Epidural anesthesia and acutely increased intracranial pressure. Lumbar epidural space hydrodynamics in a porcine model. Anesthesiology. 1996;85:1086–1091.
5. Hirabayashi Y, Shimizu R, Matsuda I, Inoue S. Effect of extradural compliance and resistance on spread of extradural analgesia. Br J Anaesth. 1990;65:508–513.
6. Hilt H, Gramm HJ, Link J. Changes in intracranial pressure associated with extradural anaesthesia. Br J Anaesth. 1986;58:676–680.
7. Liao YJ, Dillon WP, Chin CT, McDermott MW, Horton JC. Intracranial hypotension caused by leakage of cerebrospinal fluid from the thecal sac after lumboperitoneal shunt placement. Case report. J Neurosurg. 2007;107:173–177.
8. Chestnut DH, Geiger M, Bates JN, Choi WW. The influence of pH-adjusted 2-chloroprocaine on the quality and duration of subsequent epidural bupivacaine analgesia during labor: a randomized, double-blind study. Anesthesiology. 1989;70:437–441.
9. Leffert LR, Schwamm LH. Neuraxial anesthesia in parturients with intracranial pathology: a comprehensive review and reassessment of risk. Anesthesiology. 2013;119:703–718.
10. Vander Ark GD, Kempe LG, Smith DR. Pseudotumor cerebri treated with Lumbar-peritoneal shunt. JAMA. 1971;217:1832–1834.
11. Bédard JM, Richardson MG, Wissler RN. Epidural anesthesia in a parturient with a lumboperitoneal shunt. Anesthesiology. 1999;90:621–623.
12. Kim K, Orbegozo M. Epidural anesthesia for cesarean section in a parturient with pseudotumor cerebri and lumboperitoneal shunt. J Clin Anesth. 2000;12:213–215.
13. Bradley NK, Liakos AM, McAllister JP II, Magram G, Kinsman S, Bradley MK. Maternal shunt dependency: implications for obstetric care, neurosurgical management, and pregnancy outcomes and a review of selected literature. Neurosurgery. 1998;43:448–460.
14. Aly EE, Lawther BK. Anaesthetic management of uncontrolled idiopathic intracranial hypertension during labour and delivery using an intrathecal catheter. Anaesthesia. 2007;62:178–181.
15. Abouleish E, Ali V, Tang RA. Benign intracranial hypertension and anesthesia for cesarean section. Anesthesiology. 1985;63:705–707.
Copyright © 2019 International Anesthesia Research Society