A hemothorax after thoracic epidural anesthesia

Inadvertent Placement of Thoracic Epidural Catheter in Pleural Cavity: A Case Report and Review of Published Literature

Thoracic epidural placement is considered the gold standard for pain management for abdominal or thoracic surgery. It provides analgesia superior to that provided by opioids with a decreased risk of pulmonary complications. Insertion of a thoracic epidural catheter requires the knowledge and expertise of an anesthetist; epidural catheter insertion may be challenging especially when sited in the higher thoracic region, in patients with unusual neuraxial anatomy, patients unable to position adequately for insertion or morbidly obese patients. Postoperatively the anesthetic team is required to look after the patient and assess for any complications such as hypotension. Even though the incidence of complications may be low; however, some of these could have detrimental consequences for the patients such as epidural abscess, hematoma formation, and temporary or permanent neurological damage. In this case report, we will discuss a patient who underwent a three-stage esophagectomy for esophageal squamous cell carcinoma under general anesthesia with epidural analgesia. The epidural catheter (Portex® Epidural Minipack System with NRFit® connector, ICUmedical, USA) was found in the intrapleural space during video-assisted thoracoscopy for the thoracic part of esophagectomy. To facilitate surgical access, the catheter was removed immediately, and the patient was given patient-controlled analgesia with morphine for postoperative pain control.

Epidural catheter misplaced into the thoracic cavity: Utilized to provide interpleural analgesia

Thoracic epidural analgesia is one of the most effective and time-tested modalities of providing postthoracotomy pain relief. It improves postoperative pulmonary outcome. Nevertheless, being a blind procedure several complications have been associated with the technique. Pleural puncture is one rare complication that might occur following thoracic epidural catheterization. We have discussed a patient who underwent a right thoracotomy for excision of emphysematous bulla of lung under general anesthesia with thoracic epidural. The epidural catheter was misplaced in the pleural cavity and was detected intraoperatively after thoracotomy. The catheter was left in situ and was successfully utilized to provide postoperative analgesia via the interpleural route.

Intercostal misplacement of a thoracic epidural catheter -A case report-

Epidural block is useful for chronic pain and thoracic surgery. However, there are several complications, which include vessels or dural puncture, pleural puncture, misplacement of epidural catheter and trauma to the spinal cord. We report a case of intercostal misplacement of an epidural catheter in a 66-year-old patient who scheduled for left thoracotomy.

Pleural puncture: an unusual complication of a thoracic epidural

Thoracic epidural analgesia is a common method of pain relief for major thoracic and abdominal surgery. Numerous complications may occur, including temporary or permanent neurological injury. A rare and potentially life-threatening complication of thoracic epidural analgesia is pleural puncture by the needle or the catheter. Such a case is presented and pleural puncture in association with attempted thoracic epidural catheter placement is discussed.

Interpleural misplacement of an epidural catheter

We report a case of interpleural misplacement of an epidural catheter possibly caused by inappropriate angle of the Tuohy needle. A 71-year-old man was scheduled for left lower lobectomy of the lung with general and epidural anesthesia. A 18-gauge Tuohy needle was introduced into the Th5-Th6 interspace with a right paramedian approach. The direction of the epidural needle was at an angle of about 30 degrees from the skin directed cephalad. The needle was advanced 8 cm from the skin, where loss-of-resistance feeling was evident, and an epidural catheter was easily inserted 5 cm beyond the needle tip. Administration of 7 ml of 1.5% lidocaine given 20 minutes before skin incision did not alter arterial blood pressure or heart rate. Thoracotomy was performed via the fifth intercostal space. The surgeon then found the epidural catheter to be in the left pleural cavity. The catheter was immediately withdrawn. It is, therefore, necessary to employ the appropriate angle of the Tuohy needle on attempting epidural anesthesia to avoid the complication that we experienced.

Accidental pleural puncture by a thoracic epidural catheter

We report the occurrence of an accidental pleural puncture by an epidural catheter that happened during the attempted induction of thoracic epidural anaesthesia using a paramedian approach in an awake patient. The incorrect placement of the catheter was recognised while the patient was undergoing thoracoscopic surgery. The possibility of accidental pleural puncture during attempted thoracic epidural catheter placement by either the paramedian or the midline approach should be borne in mind. A misplaced catheter may injure lung tissue and result in a potentially dangerous intra-operative tension pneumothorax.