Clinically unrecognized intravascular placement of epidural catheter in a child – an argument for the use of radio‐opaque contrast?

Abstract

An epidural catheter was inserted after induction of anesthesia in a 28.2 kg 9-year-old boy scheduled to undergo bilateral femoral varus derotational osteotomies. There was no gravity free flow of blood down the catheter and there was no blood aspirated with a 2 ml syringe. After a negative test dose of a 4 ml solution of 0.25% levobupivacaine with epinephrine 1 : 200 000, a further 8 ml was administered via the epidural catheter. No significant increase in heart rate was noted. On surgical skin incision the heart rate increased from 94 to 116 b.min(-1) and blood pressure increased from 104/44 to 116/46 mmHg. A further 3 ml 0.25% levobupivacaine with epinephrine and clonidine 2 mug.kg(-1) were administered via the epidural catheter. The operation continued uneventfully although it was noted that the heart rate increased intermittently during the procedure. In view of the unexplained tachycardia and a history of cerebral palsy with the potential for postoperative muscle spasms, it was felt important to have a reliable epidural. To confirm placement, 2 ml of Isovue 300 (Iopamidol) was administered via the epidural catheter. X-ray screening demonstrated intravascular placement and the rapid disappearance of contrast. The catheter was removed and reinserted. Contrast demonstrated good spread in the epidural space. The merits of screening with contrast for epidural catheter placement in children are discussed.

Prevention of Local Anesthetic Systemic Toxicity

“…32,33 Taken together, these reports confirm that even when the needle is visualized using the in-line technique, the tip is not always accurately identified. Another imaging proposal has been the suggested use of radiopaque contrast dye when placing catheters, 34 but this would not seem to be practical in common use.…”

Pediatric regional anesthesia: what is the current safety record?

“…Direct visualization of the location of the needle tip and the injectate with ultrasound may provide additional or alternative confirmation of lack of IV injection (14). Epidurography has been reported to detect unsuspected IV epidural catheter placement even when test doses were negative (15).…”

Perioperative management of the child on long‐term opioids

“…The partially effective epidural block can be problematic. Insertion depth and position can be checked with ultrasound although this may be difficult in older children; an epidurogram will confirm the location of the catheter tip in all patients and detect subdural placement as well as placement outside the epidural space (83). A small bolus of local anesthesia (e.g., lidocaine) may help ascertain effect, and the addition of epidural clonidine may rescue a poor epidural.…”