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[Accidental subdural catheterization discovered after postoperative respiratory depression]
A Okuyama1, N Makise, O Kemmotsu
1Department of Anesthesiology, Hokkaido University, School of Medicine, Sapporo.
Abstract:
A 65-year-old man scheduled for gastrectomy was anesthetized with nitrous oxide combined with continuous epidural lidocaine. At the end of the operation, morphine 2 mg diluted in 0.25% bupivacaine 5 ml was injected through the epidural catheter. Seventy minutes later, the patient developed life-threatening respiratory depression which was antagonized by naloxone. The patient requested no analgesic during the first 26 postoperative hours. The respiratory depression in this patient was assumed to be caused by epidural morphine. Then subdural catheterization was confirmed radiologically. This was discovered to have resulted from migration of the epidural catheter into the subdural space. Subdural injection of morphine may have resulted in higher cerebrospinal fluid levels than the levels obtained after epidural injection. Subdural catheterization is a complication of epidural anesthesia that probably occurs more frequently than previously recognized. In postoperative patients receiving epidural morphine, their respiratory status should be monitored closely for hours.
Insights
Epidural catheter migration into the subdural space can cause severe respiratory depression after surgery. Close monitoring of patients receiving epidural morphine is crucial for early detection and management of this complication.
Area of Science:
- Anesthesiology
- Neurosurgery
- Pharmacology
Background:
- Continuous epidural lidocaine and nitrous oxide anesthesia were used for a gastrectomy.
- Postoperative analgesia was initiated via epidural catheter with morphine and bupivacaine.
Observation:
- A patient experienced life-threatening respiratory depression 70 minutes after epidural injection.
- The respiratory depression was reversed with naloxone, indicating an opioid effect.
Findings:
- Radiological confirmation revealed the epidural catheter had migrated into the subdural space.
- Subdural morphine administration may lead to higher cerebrospinal fluid concentrations than epidural administration.
Implications:
- Subdural catheterization is a potentially underrecognized complication of epidural anesthesia.
- Vigilant respiratory monitoring is essential for patients receiving postoperative epidural morphine to prevent adverse events.