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LETTERS TO EDITOR
Year : 2022  |  Volume : 16  |  Issue : 4  |  Page : 512-513

Cutaneous fluid leak from the epidural puncture site after insertion of a thoracic epidural catheter: A unusual cause


1 Department of Anaesthesiology, All India Institute of Medical Sciences, Patna, Bihar, India
2 Department of Trauma and Emergency, All India Institute of Medical Sciences, Patna, Bihar, India

Correspondence Address:
Neeraj Kumar
Assistant Professor, Department of Trauma and Emergency, Room No. 504, 5th Floor, OT Complex IPD, B-Block, All India Institute of Medical Sciences (AIIMS), Patna, Bihar - 801 505
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sja.sja_230_22

Rights and Permissions
Date of Submission16-Mar-2022
Date of Decision17-Mar-2022
Date of Acceptance17-Mar-2022
Date of Web Publication03-Sep-2022
 


How to cite this article:
Jha L, Kumar N, Ahmad S. Cutaneous fluid leak from the epidural puncture site after insertion of a thoracic epidural catheter: A unusual cause. Saudi J Anaesth 2022;16:512-3

How to cite this URL:
Jha L, Kumar N, Ahmad S. Cutaneous fluid leak from the epidural puncture site after insertion of a thoracic epidural catheter: A unusual cause. Saudi J Anaesth [serial online] 2022 [cited 2022 Sep 29];16:512-3. Available from: https://www.saudija.org/text.asp?2022/16/4/512/355518



Epidural catheter occlusion, kinking are common complications encountered while placing epidural causing failure of administering the drug through it.[1] However, leakage due to the kinking of the catheter is uncommon. We encountered such a problem during the use of an epidural catheter set for perioperative analgesia. A 26-year-old American Society of Anesthesiologists (ASA)-II female with a bodyweight of 40 kg was diagnosed with Atrial Septal Defect Ostium Secundum. She was electively posted for Atrial septal defect repair through median sternotomy. General anesthesia with a thoracic epidural was planned. Under a full aseptic condition in an awake, sitting position, the skin was locally infiltrated with 3 mL of 2% lignocaine hydrochloride. Then, a Romsons Epi Kit® 18G Touhy needle 80 mm length was advanced at T6–T7 intervertebral space by midline approach. The epidural space was identified by loss of resistance to air technique at 4 cm. The catheter was advanced without resistance and fixed at 9 cm to skin level. There was a negative aspiration to cerebral spinal fluid (CSF) and blood. So, the epidural test dose was injected with 3 mL of 2% lignocaine hydrochloride and adrenaline (1:200000).

During injecting the test dose, we noticed continuous flow leakage of clear fluid from the catheter insertion site. [Figure 1]a It was dripping down and stopped while withholding the drug administration. The catheter was left in situ. We decided not to use the epidural catheter intraoperatively, and the case was managed with opioid-based multimodal analgesia. The surgery lasted for 180 min, and the entire intraoperative course was uneventful. The patient was then shifted to the postoperative care unit for close monitoring. On postoperative day 1, with continuous gentle traction, the intact catheter was removed. We noticed multiple kinks at a regular interval of 0.5 cm from the catheter tip on inspection. The consecutive kink points were opposite to each other. [Figure 1]b Upon interrogation, we suspected that after getting a loss of resistance while threading the catheter through the needle, 20 cm marking was inserted till the base of the needle before taking the needle out of the skin. The Romsons Epi Kit® catheter is made up of plasticizer-free polymer with the flexible and atraumatic soft tip with three lateral eyes. Although it is flexible, it might have kinked within the epidural space during insertion causing the inadequate length of the catheter within it as well as each turn at kinking points would have provided extra space through which the test drug may extravasate out at the insertion point. In such a case, administered drugs would have leaked causing the ineffectiveness of epidural. This problem would have been attributed to various other factors viz. port configuration, depth of insertion, method of catheter fixation to the skin, however, the materials used to manufacture catheter also remain the implicated cause.[1],[2] Previously, cerbro spinal fluid (CSF)-cutaneous fistulae have been reported, and it's being associated with a variety of clinical situations such as postneurosurgery, lumbar spinal drains, trauma, tumor, infection.[3] The interstitial cutaneous fluid leak from the puncture epidural site after catheter removal is being reported in the literature.[4] However, in our case, the fluid was neither CSF nor interstitial fluid leak because leaking was associated with pushing the test dose, and it disappeared after withholding. Hence, we should consider the possibility of catheter site leak even in case of negative aspiration to CSF/blood and causing the loss of administered drug.
Figure 1: (a) Arrow showing extra-cutaneous fluid lead from epidural puncture site. (b) Arrow showing multiple kinks at a regular interval over epidural catheter

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Informed consent

Informed consent was taken from the patient.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Toledano RD, Tsen LC. Epidural catheter design: History, innovations, and clinical implications. Anesthesiology 2014;121:9-17.  Back to cited text no. 1
    
2.
Reena, Vikram A. Fracture of epidural catheter: A case report and review of the literature. Saudi J Anaesth 2017;11:108-10.  Back to cited text no. 2
    
3.
Ennis M, Brock-Utne JG. Delayed cutaneous fluid leak from the puncture hole after removal of an epidural catheter. Anesthesia 1993;48:317–8.  Back to cited text no. 3
    
4.
Dalal KS, Shrividya C. Cutaneous fluid leakage after epidural catheter removal. J Anaesthesiol Clin Pharmacol 2015;31:133-4.  Back to cited text no. 4
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