alexa Inadequate Epidural Analgesia in a Parturient with Scoliosis Treated using the 60° Head-up Position and Additional Administration of Epidural Saline with a Local Anesthetic: A Case Report
ISSN: 2155-6148
Journal of Anesthesia & Clinical Research
Like us on:
Make the best use of Scientific Research and information from our 700+ peer reviewed, Open Access Journals that operates with the help of 50,000+ Editorial Board Members and esteemed reviewers and 1000+ Scientific associations in Medical, Clinical, Pharmaceutical, Engineering, Technology and Management Fields.
Meet Inspiring Speakers and Experts at our 3000+ Global Conferenceseries Events with over 600+ Conferences, 1200+ Symposiums and 1200+ Workshops on
Medical, Pharma, Engineering, Science, Technology and Business

Inadequate Epidural Analgesia in a Parturient with Scoliosis Treated using the 60° Head-up Position and Additional Administration of Epidural Saline with a Local Anesthetic: A Case Report

Chun-Chang Yeh, Chen-Hwan Cherng, Cheng-Chang Chang, Chih-Shung Wang and Shinn-Long Lin*

Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Taiwan

*Corresponding Author:
Shinn-Long Lin
Department of Anesthesiology
Tri-Service General Hospital and
National Defense Medical Center, Taipei, Taiwan
Tel: +886 287923311
E-mail: [email protected]

Received date: March 27, 2016; Accepted date: May 16, 2016; Published date: May 23, 2016

Citation: Yeh CC, Cherng CH, Chang CC, Wang CS, Lin SL (2016) Inadequate Epidural Analgesia in a Parturient with Scoliosis Treated using the 60° Head-up Position and Additional Administration of Epidural Saline with a Local Anesthetic: A Case Report. J Anesth Clin Res 7:623. doi:10.4172/2155-6148.1000623

Copyright: © 2016 Yeh CC, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Visit for more related articles at Journal of Anesthesia & Clinical Research

Introduction

Scoliosis is defined as lateral curvature of the spine. This condition is found in 2% of the population worldwide with a two-fold higher prevalence in women than in men [1]. The challenges faced by anesthesiologists in providing neuraxial analgesia for parturients with scoliosis are inability to identify the epidural space, multiple attempts before catheter insertion, long insertion time, patchy or inadequate analgesia, high likelihood of dural puncture, and low potential for the successful treatment of post-dural puncture headache. Here, we present a parturient with scoliosis, which had an unsatisfactory block with epidural analgesia that was successfully managed using the 60° head-up position and additional administration of epidural saline with a local anesthetic.

Case Report

A 32-year-old nulliparous woman (weight, 62 kg) was admitted at 39 weeks and 5 days of gestation following spontaneous rupture of membranes. She requested for labor analgesia. After reviewing her medical records, scoliosis since adolescence without surgical correction was noted. We assessed the location, nature, and extent of vertebral involvement by reviewing her radiographic image (Figure 1). There was no coexisting cardiopulmonary or musculoskeletal disease.

anesthesia-clinical-research-thoracolumbar-spine

Figure 1: Posterior-anterior radiograph of the chest and thoracolumbar spine.

Following aseptic preparation and injection of 2% lidocaine 80 mg (4 mL) subcutaneously, an 18-gauge Tuohy needle (PortexTM Epidural Minipack System 1, Smiths Medical, Hythe, Kent, UK) was inserted with the patient in the left lateral position. Several attempts were made to enter the epidural space at L3–4 or L2–3 using either the median or para-median approach; however, these approaches proved technically difficult owing to deviation of the midline of the spinous process by palpation. Moreover, accidental dural puncture at the intervertebral space of L3-4 with clear cerebrospinal fluid flow from the Tuohy needle was noted during epidural placement. Finally, a 22-gauge epidural catheter with three lateral eyes was successfully inserted into the L1-2 epidural space using the loss-of-resistance-to-air technique. The catheter was placed twelve centimeters in depth from skin.

Following injection of 2% lidocaine 40 mg (2 mL) without epinephrine through the epidural catheter as a test dose, she was returned to the supine position. Labor epidural analgesia was initiated with an initial loading dose of 8 mL of a combination of ropivacaine (1.6 mg/mL [0.16%]) and  (1 mcg/mL), followed by a continuous or background infusion rate of 2 mL/hour and a demand dose of 6 mL. The lockout interval was 15 minutes. There were no significant alterations in her vital signs subsequently.

Thirty minutes after epidural infusion, however, she complained of mild chest tightness and paresthesia accompanied with dyspnea, dizziness, and nausea. She could still feel labor pain. We considered an epidural inadequate for labor pain with suspected symptomatic high block or extension of the cephalad sensory block into the mid-thoracic segments rather than the lumbar segments. This condition might be probably due to relatively high epidural insertion site and her scoliosisrelated anatomical changes. We did some efforts and tried to improve the analgesic efficacy by withdrawing the epidural catheter for two centimeters first. However, her labor pain and chest discomfort did not improve. We then injected fentanyl 20 mL of 0.9% saline through the epidural catheter and placed her in the 60° head-up position under the impression of relatively high epidural block. Her discomfort gradually resolved with satisfactory analgesia in minutes. A healthy baby was then born through normal spontaneous delivery 7 hours after the initiation of epidural analgesia. There were no maternal or fetal complications noted.

Discussion

Epidural analgesia is a popular method of pain relief for labor. To facilitate neuraxial placement in uncorrected scoliosis patients, Ko and Leffert [2] recommended that the needle be oriented toward the convexity of the curve where the interlaminar spaces are generally large. Radiographic images in patients with scoliosis may facilitate understanding their vertebral anomalies and allowing regional techniques to be successfully performed. McLeod et al. [3] reported that ultrasonography might help to estimate the depth and location of the epidural space and facilitate insertion of epidural catheters in patients with scoliosis.

However, not all epidurals function effectively throughout labor. Troubleshooting and management options for failed blocks or suboptimal labor epidural analgesia are extremely important. Epidural catheter manipulation is a potential management option. Campbell and Tran [4] reported that withdrawing the epidural catheter a few centimeters reduces failed epidural blocks which was not effective in our case. Placement of another epidural catheter at the level of the unblocked dermatome [5] or replacing the epidural catheter might help too. However, there are still problems such as difficult technique due to anatomic anomaly, possible local anesthetic toxicity, and prolonged time to establish a block, and subsequent block reliability and quality with the epidural [6]. In the present case, we tried withdrawing the epidural catheter for several centimeters but there was still patchy block at the level of the unblocked dermatomes. We thereafter administered a large volume of epidural saline along with local anesthetic at a low concentration and placed the patient in the 60° head-up position to overcome the problem. The simple maneuver was effective and proved to be no other complications.

Conclusion

In our case report, we demonstrated that a large volume of a local anesthetic at a low concentration and then the 60° head-up position are effective for excessive cephalad or poor caudal spread of a local anesthetic in lumbar epidural block in a parturient with scoliosis.

References

Select your language of interest to view the total content in your interested language
Post your comment

Share This Article

Recommended Conferences

Article Usage

  • Total views: 8129
  • [From(publication date):
    May-2016 - Feb 19, 2018]
  • Breakdown by view type
  • HTML page views : 8064
  • PDF downloads : 65
 

Post your comment

captcha   Reload  Can't read the image? click here to refresh

Peer Reviewed Journals
 
Make the best use of Scientific Research and information from our 700 + peer reviewed, Open Access Journals
International Conferences 2018-19
 
Meet Inspiring Speakers and Experts at our 3000+ Global Annual Meetings

Contact Us

Agri & Aquaculture Journals

Dr. Krish

[email protected]

1-702-714-7001Extn: 9040

Biochemistry Journals

Datta A

[email protected]

1-702-714-7001Extn: 9037

Business & Management Journals

Ronald

[email protected]

1-702-714-7001Extn: 9042

Chemistry Journals

Gabriel Shaw

[email protected]

1-702-714-7001Extn: 9040

Clinical Journals

Datta A

[email protected]

1-702-714-7001Extn: 9037

Engineering Journals

James Franklin

[email protected]

1-702-714-7001Extn: 9042

Food & Nutrition Journals

Katie Wilson

[email protected]

1-702-714-7001Extn: 9042

General Science

Andrea Jason

[email protected]

1-702-714-7001Extn: 9043

Genetics & Molecular Biology Journals

Anna Melissa

[email protected]

1-702-714-7001Extn: 9006

Immunology & Microbiology Journals

David Gorantl

[email protected]

1-702-714-7001Extn: 9014

Materials Science Journals

Rachle Green

[email protected]

1-702-714-7001Extn: 9039

Nursing & Health Care Journals

Stephanie Skinner

[email protected]

1-702-714-7001Extn: 9039

Medical Journals

Nimmi Anna

[email protected]

1-702-714-7001Extn: 9038

Neuroscience & Psychology Journals

Nathan T

[email protected]

1-702-714-7001Extn: 9041

Pharmaceutical Sciences Journals

Ann Jose

[email protected]

1-702-714-7001Extn: 9007

Social & Political Science Journals

Steve Harry

[email protected]

1-702-714-7001Extn: 9042

 
© 2008- 2018 OMICS International - Open Access Publisher. Best viewed in Mozilla Firefox | Google Chrome | Above IE 7.0 version