Postoperative hysterical symptoms in a patient with epidural catheter

360 through it. A case of 50-year-old woman in advanced carcinoma of the cervix posted for Wertheim's hysterectomy, planned under combined epiduralgeneral anaesthesia. Monitors were connected after securing an intravenous access. Localisation of the epidural space was achieved via the L2-L3 interspace with the patient in the lateral position. A perifix continuous Anaesthesia kit was used. An 18-gauge Tuohy epidural needle was placed in the epidural space without difficulty using the loss-of resistance technique of air. Epidural catheter was inserted through the epidural needle. After inserting few centimeters, it was noticed that markings of the epidural catheter were absent up to 14 cm. (just after three marking i.e., at 15 cm). Catheter is inserted up to 15 cm marking with approximately 4 cm inside epidural space. Injection of the test dose via the catheter was impossible. Incremental withdrawal of the catheter did not correct this situation. The epidural catheter was eventually withdrawn completely. It was not possible with subsequent attempts to flush the catheter. Close inspection of the epidural catheter assembly unit showed that a complete absence of multiple port at the distal end (helical “eyes”) with incomplete markings [Figure 1]. Pre-insertion checking of the catheter and flushing the catheter (“injection test) would have averted this incident. Difficult or impossible injection via the epidural catheter can be a result commonly from mechanical obstruction of the epidural catheter at various levels, like accidental kinking, knotting and malposition of the catheter, occasional manufacturing defects of the catheter[1,2] (defect of the screw-cap connector) can lead to this problem. Before inserting catheter, “injection test” should be performed whenever feasible, not only for epidural catheter but also for other catheter like central venous catheter. Suman Lata Gupta, Sandeep Kumar Mishra, Lenin Babu Elakkumanan, Krishnappa Sudeep Department of Anaesthesiology & Critical Care, Jawaharlal Institute of Post-Graduate Medical Education and Research, Pondicherry, India

through it. A case of 50-year-old woman in advanced carcinoma of the cervix posted for Wertheim's hysterectomy, planned under combined epiduralgeneral anaesthesia. Monitors were connected after securing an intravenous access. Localisation of the epidural space was achieved via the L2-L3 interspace with the patient in the lateral position. A perifix continuous Anaesthesia kit was used. An 18-gauge Tuohy epidural needle was placed in the epidural space without difficulty using the loss-of resistance technique of air. Epidural catheter was inserted through the epidural needle. After inserting few centimeters, it was noticed that markings of the epidural catheter were absent up to 14 cm. (just after three marking i.e., at 15 cm). Catheter is inserted up to 15 cm marking with approximately 4 cm inside epidural space. Injection of the test dose via the catheter was impossible. Incremental withdrawal of the catheter did not correct this situation. The epidural catheter was eventually withdrawn completely. It was not possible with subsequent attempts to flush the catheter. Close inspection of the epidural catheter assembly unit showed that a complete absence of multiple port at the distal end (helical "eyes") with incomplete markings [ Figure 1]. Pre-insertion checking of the catheter and flushing the catheter ("injection test) would have averted this incident. Difficult or impossible injection via the epidural catheter can be a result commonly from mechanical obstruction of the epidural catheter at various levels, like accidental kinking, knotting and malposition of the catheter, occasional manufacturing defects of the catheter [1,2] (defect of the screw-cap connector) can lead to this problem. Before inserting catheter, "injection test" should be performed whenever feasible, not only for epidural catheter but also for other catheter like central venous catheter. Sir, We had a patient in the postoperative ward presenting with irritability, restlessness, disorientation, shouting irrelevant words, and was haemodynamically stable and saturation was normal. This was 30 minutes after total abdominal hysterectomy done under combined spinal epidural anaesthesia (Epidural placement confirmed by activating in the theatre).
On evaluation we came to know that patient had complained of pain and a trained nurse had given a top up of 0.125% Bupivacaine 6 ml through the Epidural catheter after negative aspiration of CSF/ Blood. After this immediately patient started behaving with the above symptoms and complaining of pain. She was haemodymically stable. She was not responding to oral commands, thrashing her hands and legs on the bed, was given Injection Tramadol 50 milli gram intravenously, but still the symptoms persisted, Injection Haloperidol 1milli gram was given intravenously and after 5 minutes she was calm and slept off.
We removed the epidural catheter as she was moving/ thrashing on the bed earlier, the tip was blood stained (may be due to the movement/intravascular migration). [1] After two hours, the patient was normal and did not remember any of the events except of complaining of pain in the post operative period. We observed that she was anxious prior to the procedure and no history of hysterical behaviour in the past was observed. [2] Anxiety and pain would have caused this behaviour. Intravascular migration of catheter or displacement may also contribute in terms of pain because of improper drug delivery. Proper counselling and patient preparation/education matters in perioperative patient care.

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Negative pressure pulmonary oedema and haemorrhage, after a single breath-hold: Diaphragm the culprit? Anaesthesia was maintained with isoflurane, nitrous oxide and oxygen. At the end of procedure, adequate neuromuscular reversal was achieved, as assessed by double burst stimulation on peripheral nerve monitor. An awake extubation was planned; however, on return of protective airway reflexes, patient started persistently coughing and bucking on the endotracheal tube. Through an oral airway, thorough suctioning was done prior to extubation. An episode of apparent breath-holding (held in inspiration, absent chest movements, with no capnographic trace after a downstroke, no audible stridor), lasting less than a minute after noticing it, was observed. Face mask ventilation was immediately initiated with difficulty. SpO 2 suddenly dropped to 51% and heart rate increased to 108/min. Continuous Positive Airway Pressure (CPAP) with 100% O 2 was immediately given with APL valve closed. SpO 2 returned to 98% within a few seconds. Auscultation revealed bilateral fine crepitations. Ten milligram of IV frusemide was given on suspicion of negative pressure pulmonary oedema, IV dexamethasone 8 mg was also given.
Intraoperatively, the patient received 1500 mL crystalloid, there was no major blood loss. Patient was shifted to post-operative care unit as SpO 2 was stable at 98% on 6L/min O 2 via facemask. Immediate chest X-ray was asked for. Thirty minutes after the episode, in the post-operative area, his room air saturation showed 77 to 81%. He was tachypneic (respiratory rate about 28 per minute) but not distressed, coarse crepitations were present bilaterally on auscultation, with expectoration of copious quantity of serosanguineous frothy sputum, progressing to several episodes of more sanguinous expectoration.
Chest X-ray showed significant diffuse especially perihilar infiltrates, suggestive of pulmonary oedema and alveolar haemorrhage, with prominent gastric air shadow compared with a normal pre-operative chest X-ray [ Figures 1 and 2]. ABG done on oxygen with 60% Venturi by face mask showed PaO 2 63.7 mmHg, pH 7.45, PaCO 2 29.7 mmHg, HCO 3 20.4 mmol, Base excess (BE)-2.2. ICU care and non-invasive ventilation with 8 cm H 2 O PEEP and diuresis with IV frusemide Letters to Editor