Letters to the Editor: Letters & Announcements
To the Editor:
Kenneth Drasner’s excellent editorial (1) reviewing the controversy regarding the use of chloroprocaine intrathecally contains the remark that “there is little doubt that large doses of subarachnoid chloroprocaine (such as that achieved with inadvertent injection of a ‘full’ epidural dose) can induce permanent neurological injury.” I strongly agree with this statement and would like to discuss its implications for the routine use of chloroprocaine for postpartum bilateral tubal ligations in obstetric patients with indwelling labor epidurals. Although the technique is routine at some centers and advocated in at least one textbook of obstetric anesthesia (2), I suggest that the routine use of this technique is inappropriate.
The literature from the early 1980s regarding the potential neurotoxicity of intrathecal chloroprocaine is well known (3–5). The current controversy concerning its use and the lack of understanding of the mechanism of its neurotoxicity should serve as a warning to those who routinely re-dose labor epidurals for postpartum tubal ligations, as this practice always involves the possibility of inadvertent intrathecal injection of an “epidural dose.” Although there are a variety of conflicting studies (6–8) regarding the reliability of labor epidural catheters used after various temporal intervals, a conservative estimate of reliability after more than 12 h is <90% reliability. In other words, one can expect a 10% failure rate with such catheters.
Given this potential failure rate and the fact that other options that are equally effective, such as removing the epidural catheter and placing a single-shot spinal using either lidocaine or small-dose bupivacaine with or without fentanyl or using another local anesthetic that lacks the history of chloroprocaine for neurotoxicity for the epidural, are available it may be time to reconsider the use of chloroprocaine for postpartum tubal ligations in the interests of patient safety. Transient neurologic syndrome is by definition transient. Chronic adhesive arachnoiditis is not temporary and is associated with inadvertent administration of large doses of chloroprocaine. The use of indwelling labor epidural catheters for postpartum tubal ligations themselves should be discouraged for a number of reasons including lack of reliability, potential neurotoxicity from inadvertent intrathecal administration, and the availability of numerous effective alternatives. In my opinion there is only one indication for the use of epidural chloroprocaine in obstetrics, viz. its traditional use in carbonated formulation for emergency cesarean delivery.
Philip J. Balestrieri, MA, MD
Department of Anesthesiology
University of Virginia Health Systems
1. Drasner K. Chloroprocaine spinal anesthesia: back to the future? Anesth Analg 2005;100:549–52.
2. Chestnut DH. Obstetric anesthesia: principles and practice, 3rd ed. St. Louis: Mosby Inc., 2004:415.
3. Ravindran RS, Bond VK, Tasch MD, et al. Prolonged neural blockade following regional analgesia with 2-chloroprocaine. Anesth Analg 1980;59:447–51.
4. Reisner LS, Hochman BN, Plumer MH. Persistent neurologic deficit and adhesive arachnoiditis following intrathecal 2-chloroprocaine injection. Anesth Analg 1980;59:452–4.
5. Moore D, Spierkijk J, van Kleef J, et al. Chloroprocaine neurotoxicity: four additional cases. Anesth Analg 1982;61:155–9.
6. Lawlor M, Weiner M, Fantauzzi M, Johnson C. Efficacy of epidural anesthesia for post-partum tubal ligation utilizing indwelling labor epidural catheters. Reg Anesth 1994;19:54.
7. Vincent RD, Reid RW. Epidural anesthesia for postpartum tubal ligation using epidural catheters placed during labor. J Clin Anesth 1993;5:289–91.
8. Goodman EJ, Dumas SD. The rate of successful reactivation of labor epidural catheters for postpartum tubal ligation surgery. Reg Anesth Pain Med 1998;23:258–61.