1/63. Epidural hematoma following epidural catheter placement in a patient with chronic renal failure.PURPOSE: We report a case of epidural hematoma in a surgical patient with chronic renal failure who received an epidural catheter for postoperative analgesia. Symptoms of epidural hematoma occurred about 60 hr after epidural catheter placement. CLINICAL FEATURES: A 58-yr-old woman with a history of chronic renal failure was admitted for elective abdominal cancer surgery. Preoperative laboratory values revealed anemia, hematocrit 26%, and normal platelet, PT and PTT values. General anesthesia was administered for surgery, along with epidural catheter placement for postoperative analgesia. Following uneventful surgery, the patient completed an uneventful postoperative course for 48 hr. Then, the onset of severe low back pain, accompanied by motor and sensory deficits in the lower extremities, alerted the anesthesia team to the development of an epidural hematoma extending from T12 to L2 with spinal cord compression. Emergency decompressive laminectomy resulted in recovery of moderate neurologic function. CONCLUSIONS: We report the first case of epidural hematoma formation in a surgical patient with chronic renal failure (CRF) and epidural postoperative analgesia. The only risk factor for the development of epidural hematoma was a history of CRF High-risk patients should be monitored closely for early signs of cord compression such as severe back pain, motor or sensory deficits. An opioid or opioid/local anesthetic epidural solution, rather than local anesthetic infusion alone, may allow continuous monitoring of neurological function and be a prudent choice in high-risk patients. If spinal hematoma is suspected, immediate MRI or CT scan should be done and decompressive laminectomy performed without delay.- - - - - - - - - - ranking = 1keywords = catheter (Clic here for more details about this article) |
2/63. Epidural catheter and increased prothrombin time after right lobe hepatectomy for living donor transplantation.Implications: Donor right hepatic lobectomy for the purpose of living liver transplantation may be associated with postoperative abnormalities in tests of clotting function. This study explores the possible causes and anesthetic implications of this phenomenon.- - - - - - - - - - ranking = 0.57142857142857keywords = catheter (Clic here for more details about this article) |
3/63. Continuous shoulder analgesia via an indwelling axillary brachial plexus catheter.Continuous interscalene brachial plexus blockade can provide anesthesia and analgesia in the shoulder region. Difficulty accessing the interscalene space and premature displacement of interscalene catheters may preclude their use in certain situations. We present two case reports in which a catheter was advanced from the axilla along the brachial plexus sheath to the interscalene space to provide continuous cervicobrachial plexus analgesia. In the first case report, previous neck surgery made the anatomic landmarks for performing an interscalene block very difficult. An epidural catheter was advanced from the axillary brachial plexus sheath to the interscalene space under fluoroscopic guidance. This technique provided both intraoperative analgesia for shoulder surgery as well as 24-hour postoperative analgesia by an infusion of 0.125% bupivacaine. In the second case report, a catheter was inserted in a similar fashion from the axillary to the interscalene space to provide 14 days of continuous analgesia in the management of complex regional pain syndrome. We have found that this technique allows us to secure the catheter more easily than with the traditional interscalene approach and thus prevents premature dislodgment. This approach may be a suitable alternative when either an interscalene or an infraclavicular catheter may not be inserted.- - - - - - - - - - ranking = 1.4285714285714keywords = catheter (Clic here for more details about this article) |
4/63. Intraspinal haematoma following lumbar epidural anaesthesia in a neonate.A neonate with chromosomal 9 abnormality and omphalocele received a lumbar epidural catheter after laparotomy. Several attempts were needed to establish this catheter. Bleeding occurred from the operative wound after surgery. Using an epidural infusion with ropivacaine 0.1% for 48 h postoperative pain relief was sufficient. Four days after epidural catheter removal, dysfunction of the sacral parasympathetic nerves was noted. Motor and sensor function of the lower limbs were unaffected. magnetic resonance imaging showed a localized intraspinal haematoma in the lower lumbar region.- - - - - - - - - - ranking = 0.42857142857143keywords = catheter (Clic here for more details about this article) |
5/63. The role of laparoscopic biopsies in lumbar spondylodiscitis.The infection of an intervertebral disk is a serious condition. The diagnosis often is elusive and difficult to make. It is imperative to have appropriate microbiologic specimens before the initiation of treatment. We report the case of a 51-year-old woman with lumbar spondylodiscitis caused by infection after the placement of an epidural catheter for postoperative analgesia. A spinal magnetic resonance imaging (MRI) scan confirmed the diagnosis, but computed tomography (CT)-guided fine-needle biopsy did not yield adequate material for a microbiologic diagnosis. Laparoscopic biopsies of the involved disk provided good specimens and a diagnosis of propionibacterium acnes infection. We believe that this minimally invasive procedure should be performed when CT-guided fine-needle biopsy fails to yield a microbiologic diagnosis in spondylodiscitis.- - - - - - - - - - ranking = 0.14285714285714keywords = catheter (Clic here for more details about this article) |
6/63. Vertebral osteomyelitis secondary to epidural catheter use: a case report.STUDY DESIGN: A case of vertebral osteomyelitis secondary to epidural catheter use is reported. OBJECTIVE: To investigate the occurrence of vertebral osteomyelitis after the use of an epidural catheter. SUMMARY OF BACKGROUND DATA: Vertebral osteomyelitis is a rare but serious complication of epidural catheter use that apparently has not been reported previously in orthopedic literature. methods: A patient underwent abdominal surgery, and an epidural catheter was used for postoperative pain relief. He presented 3 months later with severe midlumbar pain. magnetic resonance imaging and microbiologic examination of a specimen obtained at open biopsy were used in the investigation. RESULTS: magnetic resonance imaging suggested vertebral osteomyelitis involving L1-L3. The patient underwent open debridement and posterior instrument stabilization. Biopsies taken from L3 pedicles yielded pseudomonas aeruginosa, which had been recovered earlier from the epidural catheter tip. CONCLUSION: Vertebral osteomyelitis is a rare but serious complication of epidural catheter use.- - - - - - - - - - ranking = 1.4285714285714keywords = catheter (Clic here for more details about this article) |
7/63. A portable mechanical pump providing over four days of patient-controlled analgesia by perineural infusion at home.BACKGROUND AND OBJECTIVES: Local anesthetics infused via perineural catheters postoperatively decrease opioid use and side effects while improving analgesia. However, the infusion pumps described for outpatients have been limited by several factors, including the following: limited local anesthetic reservoir volume, fixed infusion rate, and inability to provide patient-controlled doses of local anesthetic in combination with a continuous infusion. We describe a patient undergoing open rotator cuff repair who was discharged home with an interscalene perineural catheter and a mechanical infusion pump that allowed a variable rate of continuous infusion, as well as patient-controlled boluses of local anesthetic for over 4 days. CASE REPORT: A 77-year-old woman, who had previously required a 3-day hospital admission for acute postoperative pain following an open repair of her left rotator cuff, presented for an open repair of her contralateral rotator cuff. Preoperatively she received an interscalene block and perineural catheter. After the procedure she was discharged home with a portable pump that infused ropivacaine continuously at a rate of 6 mL/h and allowed a 2-mL patient-controlled bolus every 20 minutes (550-mL reservoir). The basal infusion was decreased, as tolerated, by having the patient reprogram the pump with instructions given over the telephone. Without the use of any oral opioids, the patient scored her surgical pain 0 to 1 (on a scale of 0 to 10) while at rest and 2 to 3 for 2 physical therapy sessions during which she used the bolus function to reinforce her analgesia. After 98 hours of infusion, the patient's husband removed the catheter with instructions given over the telephone, and her subsequent surgical pain was treated with oral opioids. CONCLUSION: Continuous, perineural local anesthetic infusions are possible on an ambulatory basis for multiple days using a portable, programmable pump that provides a variable basal infusion rate, patient-controlled boluses, and a large anesthetic reservoir.- - - - - - - - - - ranking = 0.57142857142857keywords = catheter (Clic here for more details about this article) |
8/63. Opioid-free analgesia following total knee arthroplasty--a multimodal approach using continuous lumbar plexus (psoas compartment) block, acetaminophen, and ketorolac.BACKGROUND AND OBJECTIVES: Traditionally, postoperative analgesia following total knee arthroplasty (TKA) has been provided by neuraxial or peripheral regional techniques with supplemental administration of opioids. We report an alternative method of postoperative pain management for patients undergoing TKA in whom the use of systemic or neuraxial opioids may result in significant side effects. CASE REPORT: A 74-year-old woman with a history of protracted nausea and vomiting after systemic and neuraxial opioid administration presented for left total knee arthroplasty. A spinal anesthetic with postoperative continuous lumbar plexus (psoas) analgesia was planned. A quadriceps motor response was elicited and a 20-gauge catheter was advanced through an 18-gauge insulated Tuohy needle into the psoas sheath. After 30 mL of bupivacaine 0.5% with 100 microg clonidine was administered through the psoas catheter, a spinal anesthetic (2 mL 0.5% bupivacaine at the L2-3 interspace) was performed. A continuous psoas infusion of 0.2% bupivacaine with 2 microg/mL clonidine at 8 mL/h was initiated in the recovery room. The psoas infusion was subsequently changed to 0.2% bupivacaine without clonidine and the rate increased to 10 mL/h. Supplemental analgesia with oral acetaminophen 1 g every 4 to 6 hours alternating with intravenous ketorolac 15 mg every 6 hours provided satisfactory analgesia, with visual analog scale (VAS) scores of 0 to 2 at rest and 3 to 4 with movement. The psoas catheter was removed 48 hours postoperatively because of prolongation of the prothrombin time. VAS scores remained 0 to 3 throughout the remainder of her hospitalization. CONCLUSION: A multimodal approach consisting of continuous lumbar plexus (psoas) block and nonopioid analgesics successfully provided postoperative pain relief in our patient and facilitated her physical rehabilitation after total knee arthroplasty.- - - - - - - - - - ranking = 0.42857142857143keywords = catheter (Clic here for more details about this article) |
9/63. Bilateral continuous paravertebral catheters for reduction mammoplasty.Surgical procedures of the breast can result in significant postoperative pain. Paravertebral nerve blocks have been used successfully in the management of analgesia after breast surgery but are limited by a single injection. This report describes the use of bilateral paravertebral catheters to provide extended analgesia for reduction mammoplasty. A 48-year-old female underwent bilateral paravertebral catheter placement at thoracic level 3 and local anesthetic injections followed by general anesthesia for elective reduction mammoplasty. She reported no pain following the operation and required no supplemental opioids for pain management during her overnight recovery. This case demonstrates a method for extended bilateral thoracic analgesia. The technique may offer an alternative to traditional outpatient analgesics for reduction mammoplasty.- - - - - - - - - - ranking = 0.85714285714286keywords = catheter (Clic here for more details about this article) |
10/63. Repeated failure of epidural analgesia: an association with epidural fat?BACKGROUND AND OBJECTIVES: To report the case of a patient who experienced repeated failed epidural analgesia associated with an unusual amount of fat in the epidural space (epidural lipomatosis). CASE REPORT: A 44-year-old female presented for an elective small bowel resection. An L(1-2) epidural catheter was placed for postoperative analgesia. The patient gave no indication of having pain at the time of emergence from general anesthesia or in the first 2 hours in the recovery room. Assessment of the level of hypoesthesia to ice while the patient was comfortable in the recovery room suggested a functional epidural catheter (cephalad level of T(10)). Two hours after admission to the recovery room the patient began to complain of increasing pain. Another 6 mL 0.25% bupivacaine was administered via the catheter. The patient's pain decreased, but remained substantial, and there was minimal evidence of sensory block above the T(10) level. Subsequently, a T(10) epidural catheter was placed. Testing confirmed proper placement of the catheter in the epidural space at the T(10) level. A test dose of 5 mL 0.25% bupivacaine resulted in prompt and complete relief of the patient's pain. However, the level of hypoesthesia to ice did not exceed the T(10) level. Approximately 1 hour later the patient complained of increasing discomfort again. There was no evidence of any sensory block, and there was no response to a bolus of 8 mL 1% lidocaine. A thorough examination of the patient did not suggest any cause for the pain other than a malfunctioning epidural catheter. A third epidural catheter was placed at the T(8-9) level. This catheter was again confirmed to be in the epidural space with a test dose of 10 mL 0.5% bupivacaine. The level of hypoesthesia to ice was restricted to a narrow bilateral band from T(7)-T(9). Analgesia failed 2 hours later. The epidural catheter was removed and the patient's pain was subsequently managed with intravenous patient-controlled analgesia (PCA) morphine. A magnetic resonance imaging (MRI) scan revealed extensive epidural fat dorsal to the spinal cord from C(5)-C(7) and from T(3)-T(9). An imaging diagnosis of asymptomatic epidural lipomatosis was established. CONCLUSION: We have described a case of repeated failure of epidural analgesia in a patient with epidural lipomatosis.- - - - - - - - - - ranking = 1.2857142857143keywords = catheter (Clic here for more details about this article) |
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