|Year : 2020 | Volume
| Issue : 1 | Page : 56-57
Return of pain in a well-working labor epidural – A cause of alert
Rakhee Goyal, Sakshi Mahajan, Sanjit Naskar, Divya Tewari, Manoj Goyal
Department of Anesthesia, Madhukar Rainbow Children's Hospital, New Delhi, India
|Date of Submission||09-Sep-2019|
|Date of Acceptance||10-Dec-2019|
|Date of Web Publication||16-Apr-2020|
Dr. Rakhee Goyal
C-9 Panchsheel Enclave, New Delhi
Source of Support: None, Conflict of Interest: None
Epidural analgesia is considered as the most effective method of labor analgesia. Intravascular catheter migration is known to occur in patients in labor. There are methods to detect an intravascular migration such as epinephrine-containing test dose and negative aspiration, but these methods are unreliable and often misleading. Therefore, a high index of suspicion is required to avert the complications of local anesthetic systemic toxicity resulting from an intravascular administration of drugs given through the epidural catheter.
Keywords: Epidural analgesia: complications, local anesthetics: systemic toxicity, uterine blood flow determinants
|How to cite this article:|
Goyal R, Mahajan S, Naskar S, Tewari D, Goyal M. Return of pain in a well-working labor epidural – A cause of alert. Indian J Pain 2020;34:56-7
| Introduction|| |
A large number of women in labor routinely request for epidural analgesia. It is important that when we attempt to keep our patients comfortable and pain-free through their journey of childbirth, we ensure that they are safe at all times. Intravascular migration of a well-working epidural is not uncommon and should be always kept in mind while managing a labor epidural analgesia.
We report a case of labor epidural where a potentially life-threatening complication of local anesthetic toxicity was averted because of vigilance, careful monitoring, and prompt action of the attending team.
| Case Report|| |
A 26-year-old, primigravida, in active labor, requested for labor analgesia. She was at 37-week gestation, with a weight of 88 kg, height 158 cm, and did not have any comorbid condition. Her complete blood count and coagulation profile were normal. After a written informed consent, combined spinal-epidural analgesia was administered to her under aseptic conditions in sitting position using 18-G epidural needle, 20-G multi-orifice catheter, and 27-G spinal needle (B. Braun Melsungen AG, Melsungen, Germany) at L3–L4 level. Fentanyl 25 mcg was given in the subarachnoid space, following which the epidural catheter was placed 4 cm in the epidural space and was secured with adhesives at 9 cm on the skin. After a careful negative aspiration of blood or cerebrospinal fluid in the catheter, an infusion of 0.2% ropivacaine with 2 mcg/ml of fentanyl was started at 5 ml/h. The heart rate, SpO2, and noninvasive blood pressure were monitored. The sensory block after 30 min of infusion was till T-8 dermatome level. The patient was comfortable for 3 h when she started complaining of progressively increasing pain during uterine contractions. The rate of infusion was increased to 8 ml/h over 15 min, but there was no improvement in the analgesia. Meanwhile, the patient complained of slight dizziness, blurring of vision, and tingling of perioral region. The epidural infusion was stopped immediately, and the resuscitation cart was brought in along with 20% intralipid. The epidural catheter was checked, and free-flowing blood could be aspirated. The catheter was withdrawn gradually by 2 cm, but blood could still be aspirated freely. The catheter was removed, and the patient was counseled. Her symptoms alleviated completely over the next 30 min and she remained clinically stable. The intralipid was withheld and she was monitored continuously. There were no changes in the electrocardiogram and there was no significant change in the blood pressure and heart rate. She was given intravenous analgesics (diclofenac [75 mg] and paracetamol [1 g]) till she delivered her baby normally.
| Discussion|| |
Intravascular migration of epidural catheter is a concern in labor epidural analgesia. The epidural veins are markedly engorged and can get further distended during uterine contractions. The patients in labor are more mobile and active compared to the postoperative patients who have epidural catheters in situ. In a retrospective analysis of 19,259 deliveries by Pan et al., 75% of patients received an epidural or a combined spinal-epidural analgesia. Six percent of the epidural catheters were intravascular during the initial placement, whereas the incidence of late intravascular migration was 0.25%.
When there is a sudden increase in pain in an otherwise well-working epidural, there is a possibility of catheter migration. The loss of analgesia can occur if the catheter is out of the epidural space or it has entered an epidural vein. Intravascular injection of local anesthetics can be life-threatening and warrants immediate attention in an obstetric patient. Jeon et al. reported a case where local anesthetic was given for the cesarean section in an epidural catheter originally used in labor effectively for more than 3 h, and the patient showed features of local anesthetic systemic toxicity immediately after the drug administration. Although the fractionation of epidural doses is recommended and large boluses are discouraged in labor, in cases of conversion to the cesarean section, a bolus of a fast-acting local anesthetic is given along with appropriate adjuvants. This can be a safety threat in a hurried situation when there is fetal distress, and time is a concern for an operative delivery.
The practice of test dose with epinephrine is controversial for labor epidurals. The interpretation of heart rate can be unreliable during uterine contractions. There is a possible attenuation of the chronotropic response to epinephrine in pregnancy, and epinephrine can reduce the uterine blood flow. However, some institutes routinely use test dose to rule out an intravascular and subarachnoid placement, while others have shown evidence of safety without any test dose. Moreover, it can be argued that after an initial negative test dose, when an infusion is used to administer drugs through the epidural catheter, repeated subsequent testing is not feasible.
The epidural veins are low-pressure veins without any valves, and there are high false negatives on aspiration through a single-orifice catheter. The use of multi-orifice catheters is encouraged, but the eyes may also be blocked when the catheter is kept in situ for sometime. Therefore, there is no confirmatory method to detect an intravascular migration of an epidural catheter in the patients in labor. Hence, a high index of suspicion for an intravascular migration is required when there is a sudden increase in pain in a previously functioning epidural. The local anesthetic should be immediately stopped, the epidural catheter should be checked, and the patient should be monitored. In case of local anesthetic toxicity, immediate supportive management should be started along with an infusion of 20% intralipid.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Pan PH, Bogard TD, Owen MD. Incidence and characteristics of failures in obstetric neuraxial analgesia and anesthesia: A retrospective analysis of 19,259 deliveries. Int J Obstet Anesth 2004;13:227-33.
Jeon J, Lee IH, Yoon HJ, Kim MG, Lee PM. Intravascular migration of a previously functioning epidural catheter. Korean J Anesthesiol 2013;64:556-7.
Guay J. The epidural test dose: A review. Anesth Analg 2006;102:921-9.
Bell DN, Leslie K. Detection of intravascular epidural catheter placement: A review. Anaesth Intensive Care 2007;35:335-41.