Serious Complications After Epidural Catheter Placement: Two Case Reports

Abstract

Thoracic epidural analgesia (TEA) is a standard procedure in multimodal analgesia applied in major thoracic and abdominal surgeries. Two cases are presented with serious complications related to TEA. In both cases, earlier reaction of the treating physicians to patient-reported sensory symptoms could have prevented the complicated course. The first case was a 73-year-old patient with bronchial carcinoma who underwent right lower lobe resection. In this case, dabigatran 150 mg/d (indication: permanent atrial fibrillation) had been discontinued 72 hours before surgery, and enoxaparin 80 mg (every 12 hours) had been started 11 hours after surgery. An epidural hematoma developed postoperatively. Magnetic resonance imaging (MRI) was performed only after paraplegia had developed the next day. Unfortunately, delayed hematoma evacuation could not prevent persistent paraplegia in this case, which was complicated by hospital-acquired pneumonia with sepsis and acute renal failure. The second case was a 39-year-old patient with ulcerative colitis and an initially undetected malposition of the epidural catheter. Immediately after test bolus injection, the patient reported paresthesia and overall discomfort, which however could not be safely attributed to either the test dose or the already started general anesthesia. The patient could only be extubated after stopping the epidural infusion. Accidental re-start of epidural infusion led to coma, conjugate eye deviation, and respiratory arrest, necessitating re-intubation. Computed tomography (CT) ruled out intracerebral pathology and showed a catheter position centrally in the spinal canal. Fortunately, no neurological deficits were detected after catheter removal.

Keywords: dabigatran; epidural analgesia; paraplegia; perioperative complications.

Figure 1

Midsagittal T2-weighted MR image showing the epidural hematoma (red arrow) with compression of the thoracic spinal cord at the level of the vertebral bodies Th4 and Th5.

Figure 2

Detail enlargements of axial (A–C) and sagittal (D) thoracic CT scans in a soft tissue window at level Th9. Red arrows indicate epidural catheter (white dot). (A) (left upper panel): The catheter is shown passing the ligamentum flavum ventral to the spinous process. (B) (right upper panel): Imaging of the catheter in the epidural space. (C) (left lower panel): Catheter position almost in the middle of the dural sac, suggesting a position inside the spinal cord. (D) (right lower panel): Entry of the epidural catheter into the dural sac. The terminal 4 centimeters of the catheter are not shown. Additional findings: consolidations (atelectasis) of the posterior lower lobes, nasogastric tube.

Figure 3

Shaded surface display volume rendering (SS-VRT) of the thoracic vertebral column in head-feet-orientation: central, slightly right paramedian, position of the catheter inside the spinal canal. Red arrows indicate catheter.