Pneumoretroperitoneum after Attempted Epidural Anesthesia

Abstract

Air may extend to the retroperitoneal space from retroperitoneal perforation of a hollow viscus, infection of the anterior pararenal space with gas-forming organisms and from pneumothorax or pneumomediastinum [1]. Rare pathologies, such as open reduction and internal fixation of femoral fractures and anaerobic abscess of the hip joint have also been described in relation to this complication [1,2]. A rare case of pneumoretroperitoneum caused by insufflation of air during an attempt to achieve epidural anesthesia is described. Case reportAn 81-year-old, Caucasian, male, weight 72 kg, height 178 cm, was admitted due to fracture of the neck of the right femur. The patient was operated on, and internal fixation of the fracture was performed. Epidural anesthesia at the L4-5 level in the right the lateral position was performed by a second-year anesthesia resident. A midline approach and an 18G Tuohy needle were used. The procedure was technically difficult, and a total of three attempts were made. Loss of resistance with air was used. During the efforts to identify the epidural space, some 30 to 35 milliliters of air had been injected. Subjective loss of resistance was reported by the performing anesthesiologist. However, he was unable to insert an epidural catheter. Local anesthetic was not injected. The procedure was eventually carried out without intraoperative complications under general anesthesia. On the fourth postoperative day, the patient developed continuous abdominal pain of moderate severity. On examination, there were no signs of peritoneal irritation. However, an abdominal CT scan demonstrated air in the retroperitoneum around the left psoas muscle (Figure 1). Because the patient had received an enema on the third postoperative day, a gastrografin enema was performed to rule out rectal or colonic perforation. No leak was demonstrated. CT examination confirmed air around the left psoas muscle which extended to the left paravertebral muscles. There was no air around the pelvic organs or at the site of the femoral fixation. The patient's condition improved gradually, and he was discharged on the seventh postoperative day. The patient agreed with presentation of his data and all the procedures performed were approved by the institution where the patient was treated.

Epidural Anaesthesia: How Easy Is It to Walk on Quicksand?

“…In this issue of The Journal of Critical Care Medicine, Isakov et al described a very rare complication following a difficult attempt at epidural anaesthesia using LOR with air in an 81-old man undergoing hip surgery [17]. Following an injection of about 35 ml of air, on the fourth postoperative day, the patient complained of moderate abdominal pain without peritoneal irritation signs.…”