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DURAL PUNCTURE by an extradural catheter threaded through a needle correctly positioned in the extradural space is a well known albeit rare, complication of continuous extradural analgesia. ~-3 The subarachnoid location of the catheter, if not detected by aspiration ofcerebrospinal fluid or after a test of local anaesthetic, is usually recognized when an unduly high* or total spinal block results from the first injection of local anaesthetic. A case is reported here of a dural perforation recognized late during an apparently normal extradural block. CASE REPORTA 68-year-old man (weight 67k g, height 170cm) was scheduled for a left femoral popliteal by-pass graft for chronic arterial insufficiency. His medical history was unremarkable apart from mild hypertension treated with methyldopa and =hlorthalidone; physical examination and laboratory findings were normal. A 16-gauge Tuohy needle was inserted between L2-L3 with the patient in left lateral position and the epidural space identified using the loss-of-resistance test with air. A Portex epidural catheter was inserted 4cm into the epidural space with some difficulty. As blood was aspirated persistently, the catheter was removed and a second epidura] puncture was made between LI-L2. This time the catheter was easily inserted 3cm into the space and no paresthesiae were elicited. When careful aspiration failed to produce fluid, a Millipore filter was attached to the hub of the catheter and 15ml of bupivacaine 0.5 per cent were injected with the patient in left lateral position. During the following 15 minutes pin-prick analgesia tested only on the left side rose to T8 and the blood pressure decreased from 160torr (21.3kPa) to 140torr (18.6kPa) after infusion of one litre of Hartmann's solution. Two hours later a reinforcement dose of 10ml of 0.5 per cent bupivacaine was
DURAL PUNCTURE by an extradural catheter threaded through a needle correctly positioned in the extradural space is a well known albeit rare, complication of continuous extradural analgesia. ~-3 The subarachnoid location of the catheter, if not detected by aspiration ofcerebrospinal fluid or after a test of local anaesthetic, is usually recognized when an unduly high* or total spinal block results from the first injection of local anaesthetic. A case is reported here of a dural perforation recognized late during an apparently normal extradural block. CASE REPORTA 68-year-old man (weight 67k g, height 170cm) was scheduled for a left femoral popliteal by-pass graft for chronic arterial insufficiency. His medical history was unremarkable apart from mild hypertension treated with methyldopa and =hlorthalidone; physical examination and laboratory findings were normal. A 16-gauge Tuohy needle was inserted between L2-L3 with the patient in left lateral position and the epidural space identified using the loss-of-resistance test with air. A Portex epidural catheter was inserted 4cm into the epidural space with some difficulty. As blood was aspirated persistently, the catheter was removed and a second epidura] puncture was made between LI-L2. This time the catheter was easily inserted 3cm into the space and no paresthesiae were elicited. When careful aspiration failed to produce fluid, a Millipore filter was attached to the hub of the catheter and 15ml of bupivacaine 0.5 per cent were injected with the patient in left lateral position. During the following 15 minutes pin-prick analgesia tested only on the left side rose to T8 and the blood pressure decreased from 160torr (21.3kPa) to 140torr (18.6kPa) after infusion of one litre of Hartmann's solution. Two hours later a reinforcement dose of 10ml of 0.5 per cent bupivacaine was
Spinal analgesia using bupivacaine 0.57; plain Bupivacaine 0.5% plain solution was used to produce spinal analgesia on 63 occasions. In 33 patients ajixed dose of 4 ml injected at the L2/3 interspace at 0.5 mllsecondproduced an extent of analgesia which was directly related to patient age (P < 0.005). The latency was 17.3 minutes (SO 8.4) and duration of action was 286 minutes (SO 62). A second group receiving only I ml ofsolution hada much shorter duration of action (mean 154 minutes, SD 30). In 90% ofpatients the analgesia obtained was fully sufficient for surgery to be performed and no form of analgesic .supplementation was given. On two occasions no analgesia occurred at all. Bupivacaine 0.5% plain proved to be an eflectiue agent for subarachnoid block. The extent of analgesia was, however, poorly predictable, andeven with low doses unacceprably high 1euel.r ofhlock were sometimes achieved.
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