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 Table of Contents  
LETTER TO THE EDITOR
Year : 2022  |  Volume : 36  |  Issue : 1  |  Page : 63-64

Persistent cutaneous fluid leakage from epidural puncture site: A diagnostic challenge


Department of Anaesthesiology and Critical Care Medicine, AIIMS, Patna, Bihar, India

Date of Web Publication25-Apr-2022

Correspondence Address:
Dr. Sarfaraz Ahmad
Department of Anaesthesiology and Critical Care Medicine, AIIMS, Phulwarisharif, Patna - 801 507, Bihar
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpn.ijpn_94_21

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How to cite this article:
Ahmad S, Kumar A, Naaz S, Kumar A. Persistent cutaneous fluid leakage from epidural puncture site: A diagnostic challenge. Indian J Pain 2022;36:63-4

How to cite this URL:
Ahmad S, Kumar A, Naaz S, Kumar A. Persistent cutaneous fluid leakage from epidural puncture site: A diagnostic challenge. Indian J Pain [serial online] 2022 [cited 2022 Jul 1];36:63-4. Available from: https://www.indianjpain.org/text.asp?2022/36/1/63/343835



Sir

A 60-year-old female patient of weight 90 kg, height 168 cm, and ASA grade II was scheduled for bilateral total knee replacement surgery. The epidural space was identified at the L3–L4 intervertebral space using the loss of resistance technique with a 16G Tuohy needle, at 4.5 cm from the skin, by the midline approach, in a sitting position. 15 mg of injection bupivacaine heavy was given in the subarachnoid space using a 27G Whitacre spinal needle by needle through needle technique. The epidural catheter was secured at 9.5 cm at the level of the skin, and a test dose of 45 mg of lignocaine with adrenaline 15 μg was injected without adverse effect. The surgery was completed in 3 h uneventfully. Postoperatively, injection bupivacaine 0.125% was given as boluses for pain relief. On the 3rd postoperative day, the epidural catheter was found to be removed accidentally. The next day, clear liquid was seen leaking from the epidural catheter puncture site.

The patient's bed site was wet, and the dressing applied at the epidural site was also soaked. Clear fluid was seen dripping out of the puncture site at the rate of about 14–16 drops per minute [Figure 1]. The patient's vitals were stable, and the patient did not have any postural headache or visual or neurologic disturbances. As the surrounding tissue looked edematous, an 18-gauge needle was inserted just lateral to the site of the fluid leak. Clear fluid started trickling from the needle, which was sent for biochemical analysis along with the patient's venous blood sample. On analysis, the fluid and the venous sample both had similar values for glucose, chloride, protein, and pH. We applied compression dressing over the epidural puncture site. Progressively, the leak decreased and stopped entirely on the 6th postoperative day.
Figure 1: Leaking of fluid from the epidural catheter puncture site

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The fluid collected from the epidural puncture site was initially thought to be cerebrospinal fluid (CSF), but it was interstitial transudate fluid per biochemical examination. We could reach the diagnosis by simply analyzing the suspected fluid and comparing it with the patient's serum values and the average serum, CSF, and edema fluid values.

In our case, the cause of fluid leakage seems to be due to dependent edema present in the patient most likely from hypoproteinemia. Dalal and Shrividya have also reported a similar finding.[1] Suspected CSF leak can be confirmed by β2 transferrin immunofixation assay.[2] The risk factors for CSF leak are multiple attempts that lead to dural puncture, and fibrin deposition creates the fistulous tract's patency following epidural placement, infection, tumors, and surgery.[2],[3]

CSF leak in our case could also be ruled out as fluid leak occurred on the 4th postoperative day, while CSF fistulae usually occur before 48 h of surgery. The rate of fluid leakage from the epidural puncture site, in our case, was alarming; however, still, our patient was asymptomatic. However, simple chemical analysis can avoid time-consuming and expensive diagnostic tests if the suspected fluid can be collected minimally of 0.5 ml volume.

In conclusion, this case report shows the importance of serving simple, inexpensive, and rapid tests.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Dalal KS, Shrividya C. Cutaneous fluid leakage after epidural catheter removal. J Anaesthesiol Clin Pharmacol 2015;31:133-4.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Chan BO, Paech MJ. Persistent cerebrospinal fluid leak: A complication of the combined spinal-epidural technique. Anesth Analg 2004;98:828-30.  Back to cited text no. 2
    
3.
Abaza KT, Bogod DG. Cerebrospinal fluid-cutaneous fistula and pseudomonas meningitis complicating thoracic epidural analgesia. Br J Anaesth 2004;92:429-31.  Back to cited text no. 3
    


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