Letters to the Editor: Letters & Announcements
To the Editor:
We were interested in the recent correspondence by Eti and colleagues reporting pleural puncture after insertion of thoracic epidural catheter via midline approach (1), as well as a similar report by Patermann et al. (2). Both reports suggest measures for early detection of pleural puncture during thoracic epidural, primarily by demonstrating an adequate block before surgery.
We would like to add several additional points. At high thoracic levels the ligamentum flavum may fail to fuse in the midline, and thus it should not be relied on as a tactile landmark during thoracic epidural needle placement (3,4). If the epidural catheter is misplaced, forceful insertion may lead to disastrous complications (5–7). In our view the catheter should be inserted 1–2 h preoperatively in an awake patient. This provides ample time to place the catheter and accurately assess the level of sensory analgesia with local anesthetic drug before surgery begins.
Because pleural puncture has been reported after unilateral block (8,9), accurate positioning of the catheter is only confirmed by bilateral sensory block. Anything other than an effective bilateral block suggests that the catheter may not be correctly positioned, with pleural puncture as one of the possibilities (10).
Rajesh Mahajan, MD
Rahul Gupta, MD
Anju Sharma, MD
Department of Anesthesia
1. Eti Z, Lacin T, Yildizeli B, Gogan V, Gogus FY, Yuksel M. An uncommon complication of thoracic epidural anesthesia: pleural puncture. Anesth Analg 2005;100:1540–1.
2. Patermann B, Lynch J, Schneider P, et al. Intrathoracic positioning of a thoracic epidural catheter inserted via the median approach. Can J Anaesth 2005;52:443–4.
3. Lirk P, Kolbitsch C, Putz G. Cervical and high thoracic ligamentum flavum frequently fails to fuse in the midline. Anesthesiology 2003;99:1387–90.
4. Lirk P, Colvin J, Steger B, et al. Incidence of lower thoracic ligamentum flavum midline gaps. Br J Anaesth 2005;94:852–5.
5. Gibson P. Spinal cord damage following thoracic epidural anaesthesia. Anaesth Intensive Care 2004;32:100–3.
6. Iida A, Kashimoto S, Matsukawa T, Kumazawa T. A hemothorax following thoracic epidural anaesthesia. J Clin Anesth 1994;6:505–6.
7. Aldrete JA, Ferrari H. Myelopathy with syringomyelia following thoracic epidural anaesthesia. Anaesth Intensive Care 2004;32:596–7.
8. Zaugg M, Stoehr S, Weder W, Zollinger A. Accidental puncture by a thoracic epidural catheter. Anesthesia 53:69–71,1998.
9. Grieve PP, Whitta RKS. Pleural puncture: an unusual complication of a thoracic epidural. Anaesth Intensive Care 2004;32:113–6.
10. Whitta RKS, Grieve PP. Unilateral versus bilateral epidural block. Anaesth Intensive Care 2004;32:597–8.