Infections complicating tunneled intraspinal catheter systems used to treat chronic pain

Tunneled intraspinal catheters and catheter-pump systems are increasingly common treatments for severe chronic pain, but these long-term catheters have caused meningitis, epidural abscesses, and other serious infections. At a cancer referral center, 81 catheters were placed in 72 patients over a 7-year period. There were seven catheter-associated infections: two were meningeal (one was accompanied by an epidural abscess and one by a pocket infection and bacteremia), four were associated with a pocket, and one was associated with a tunnel. The infection rate was 0.77 per 1,000 catheter-days. Pathogenic organisms that were isolated were primarily normal skin flora. By multivariate Cox analysis, the only factor significantly associated with catheter infection was prolonged catheter placement surgery, i.e., a procedure lasting at least 100 minutes (RR, 8.8; 95% CI, 1.6-50). Three patients were cured by removal of the catheter and treatment with antibiotics, and symptoms were satisfactorily suppressed in four patients with antibiotics alone. Considering the severity of illness in catheter recipients, the infection rate was relatively low. Removal of the catheter does not appear mandatory when the goal is suppression of infection-related symptoms, especially when the infection has not spread to the CNS, the infecting organism has an intrinsically low virulence, and the infected patient is terminally ill.     

Testing an implantable intraspinal drug delivery device in the ewe

OBJECTIVE: The authors report the use of multiple implanted intraspinal port and catheter systems per test animal to study the in vivo functional characteristics and reliability of a new implantable spinal drug delivery port system. METHODS: Four ewes were each implanted with two epidural and one subarachnoid silicone elastomer catheters at the lumbar level. Each catheter was connected in series to one of three Therex filtered spinal delivery ports implanted subcutaneously in a similar grid pattern in each ewe to facilitate percutaneous identification. Saline (2 ml) was injected 3 times weekly in each port. The ease of injection and behavioral responses were recorded for 207-213 days of implantation until sacrifice/necropsy. RESULTS: All ports functioned reliably during the study. However, injection through two of the four subarachnoid catheters resulted in behavioral withdrawal responses intermittently. This behavioral pattern was much less common after epidural port injections. All four subarachnoid and four of eight epidural port and catheter systems were tested with local anesthetic just before sacrifice. Motor block was observed in three of four subarachnoid and three of four epidural port and catheter systems tested. Integrity of the other four epidural ports was tested by injection of methylene blue at sacrifice. This dye did not distribute in the epidural space in one of the latter four epidural ports (not local anesthetic tested) because of a concentric fibrotic reaction about the catheter. Similar fibrotic reactions surrounded the catheters that failed a functional test with local anesthetic. CONCLUSIONS: The implantable intraspinal port system tested functions reliably under repetitive percutaneous access. However, filtering such ports, though desirable to prevent entry of debris into the spinal canal, did not eliminate pericatheter chronic subarachnoid and epidural reaction. The number of test animals required to test 12 ports chronically was reduced by two-thirds without undue trauma to the individual test subject. Chronic percutaneous injection of an implanted subarachnoid system is feasible but may be associated with behavioral effects similar to that seen with chronic epidural systems. Fibrosis around chronic silicone catheters limited functional utility in one-fourth of the implanted test systems. Further study of the potential reactivity of chronic epidural and subarachnoid catheters is indicated.     

Thoracic versus lumbar epidural anesthesia's effect on pain control and ileus resolution after restorative proctocolectomy

BACKGROUND: Epidural anesthesia as a perioperative adjunct has been shown to provide superior pain control and has been implicated in more rapid ileus resolution after major abdominal surgery, possibly through a sympatholytic mechanism. Studies suggest that the vertebral level of epidural administration influences these parameters. METHODS: One hundred seventy-nine patients (120 male, 59 female; average age, 36 years) underwent restorative proctocolectomy for ulcerative colitis or familial polyposis between 1989 and 1995. Patients were grouped according to type of anesthesia. Group THO (n = 53) received thoracic (T6 to T10) epidurals. Group LUM (n = 51) received lumbar (L2 to L4) epidurals, and group PCA (n = 75) received patient-controlled intravenous narcotic analgesia. Patients were compared for complications, perioperative risk factors, postoperative pain, and ileus resolution. RESULTS: Epidural narcotics, alone or combined with local anesthetics, were administered for an average of 2 (LUM) to 4 (THO) days without significant complications. Infrequent problems related to the epidural catheters included self-limited headaches or back pain (four) and site infections (two). Epidural failure, as measured by conversion to PCA for inadequate pain control, was not significantly greater for LUM (25%) than THO (23%). Average pain scores, rated daily on a visual analog scale, were significantly higher (indicating more pain) for PCA patients (4.2) during postoperative days 1 through 5 than for LUM (3.5) (p < 0.05) and for THO (2.4) (p < 0.05). Ileus resolution, as determined by stool output and return of bowel sounds, was significantly faster in THO than in LUM or PCA (p < 0.05). Resolution of ileus was not significantly different between PCA and LUM (p > 0.05). CONCLUSIONS: Thoracic epidural analgesia has distinct advantages over both lumbar epidural or traditional patient-controlled analgesia in shortening parameters measuring postoperative ileus and in reducing surgical pain. The procedure is safe and associated with low morbidity. Thoracic epidural anesthesia is also economically justifiable and may prove to impact significantly on future postoperative management by reducing length of hospitalization. Our data and those of others are most striking in these regards for patients with thoracic catheters, indicating the importance of vertebral level in epidural drug administration.     

Germline mutations in PTEN are an infrequent cause of genetic predisposition to breast cancer

Spinal extradural abscess is an infrequent, but serious complication to extradural catheters. Early diagnosis is essential for successful treatment. An extradural abscess may develop slowly over days to several weeks and symptoms may be vague and unspecific, delaying correct diagnosis. Meticulous supervision of the patients is required and must continue as long as an epidural catheter is in place and for some time after the catheter has been withdrawn. This case report describes a patient undergoing extensive reconstructive plastic surgery after a leg trauma. For postoperative pain treatment a continuous epidural infusion of bupivacaine was given. After 10-14 days an extradural abscess developed with increasing low back pain but without any neurologic symptoms. With antibiotics a complete resolution of the extradural abscess occurred, documented by computerized tomography (CT).     

Increased anticoagulation during cardiopulmonary bypass by prostaglandin E1

We prospectively evaluated the diagnostic accuracy of an epinephrine-containing epidural test dose (EpiTD) as a marker of intravascular injection in 209 unmedicated laboring women. Maternal heart rate (MHR) was continuously monitored and recorded on a strip chart. A tocodynamometer monitored uterine activity. A lumbar epidural catheter was placed and aspirated. If aspiration was positive for blood or cerebrospinal fluid (CSF), the catheter was replaced. In uterine diastole and with stable MHR, 198 patients received an EpiTD (epinephrine 15 microg plus lidocaine 45 mg) via the catheter. MHR and the generated HR strip were observed. A positive EpiTD was defined as a sudden increase in MHR of 10 bpm more than the resting MHR, within one minute after the injection, with a fast acceleratory phase of more than 1 bpm. Absence of a tachycardiac response suggested a negative EpiTD. If the tachycardiac response was deemed equivocal or a uterine contraction followed the EpiTD injection within 1 min, the EpiTD was invalidated and repeated. Catheter aspiration was repeated, and the catheter was removed if aspiration was positive. All patients with negative EpiTD and aspiration received 6-12 mL of epidural bupivacaine 0.25% with or without fentanyl 50 microg. Absence of analgesia without signs or symptoms of systemic toxicity after a maximum of bupivacaine 30 mg defined failed epidural analgesia. All patients with positive EpiTD and negative aspiration received 5 mL of lidocaine 2% epidurally as a second test dose (Lido100TD). The presence of tinnitus and/or metallic taste defined a positive Lido100TD. There were 176 true negatives, 0 false negatives, 14 true positives, and 8 false positives. The sensitivity of EpiTD was 100%, the specificity 96%, the negative predictive value 100%, and the positive predictive value 63%. The prevalence of negative tests was 88%, and the prevalence of positive tests was 12%. The overall accuracy of an EpiTD was 95.5%. We conclude that EpiTD is a reliable test to identify i.v. catheters during the performance of lumbar epidural analgesia in laboring patients. Implications: Catheters inserted for epidural analgesia in laboring patients may accidentally enter a blood vessel. Local anesthetics injected through these catheters may cause seizures and cardiac arrest. In this study, we concluded that injecting a small amount of epinephrine before injecting a local anesthetic frequently helps to identify these misplaced catheters. Few catheters may actually be in the correct place even after responses to epinephrine.     

Value of combined spinal and epidural anesthesia in the management of peroperative analgesia in prosthetic surgery of the lower limb. Prospective study of 68 cases

PURPOSE OF THE STUDY: Efficient peri-operative analgesia is more comfortable, allows earlier mobilisation and better functional results for lower limb arthroplasties. We report our 60 cases prospective study of combined spinal and epidural anesthesia, and expose interests of this technique to control peri-operative pain. MATERIALS: From 1994 to 1995, 60 patients ASA class 1 were operated: 45 total hip replacement (THR), 15 total knee replacement (TKR). The average age was sixty five years (range thirty nine to eighty five years). Combined spinal and epidural anesthesia was performed in every case. METHODS: In lateral decubitus position, a translucent 25 Gauge needle was introduced in L2-L3 interspace. In a first time spinal anesthesia was made with 20 mg Bupivacaine. In a second time, a lumbar epidural catheter was inserted. All patients received an epidural post-operative analgesia with 4 mg Morphine once a day during two days and intravenous Paracetamol. Visual analogue scale (0 to 10) (VAS) were recorded after the third post operative hour and every twelve hours. During this period satisfaction mark was also recorded (1 to 3). RESULTS: We didn't observe any case of respiratory depression or infection with the epidural catheter. We observed 10 cases of pruritus (one needed to stop protocol) and 18 urinary retentions. Six uretral catheters were necessary; we had one case of pyelonephritis (escherichia coli). The first micturition was obtained 13.5 hours after the end of surgery. For the fifty nine remaining patients, visual analogue scale was always inferior or equal to 2/10 and the satisfaction mark to 1/3. DISCUSSION: Different techniques allow peri-operative analgesia, but a few are efficient during the first two days. Plexus nerve blocks are simple and reliable but post-operative anesthesia is short (inferior to 15 hours). Intravenous morphine controlled by patients themselves with programmed display needs expensive and sophisticated material. The principal risk is respiratory depression. Epidural morphine has a lower respiratory depression risk, but needs a heavier technique. The principal problems is higher incidence of urinary side effects. Epidural anesthesia might tend to show a greater efficacity with the best visual analogue scale and satisfaction mark. CONCLUSION: The results indicate that combined spinal and epidural anesthesia for the management of peri-operative pain provide an excellent pain control with a daily morphine injection. For lower limb arthroplasties, visual analogue scale is always inferior or equal to 2 and satisfaction mark equal to 1.     

Integrin signalling and tyrosine phosphorylation: just the FAKs?

PURPOSE: Physical rehabilitation is one of the major forms of treatment of chronic low back pain. The ability of some patients to cooperate is limited by pain. Since 1992 continuous epidural analgesia has been combined with a physical rehabilitation programme for patients with chronic low back pain who have been unable to make progress with conventional physical rehabilitation due to severity of pain. METHOD: This study reports a series of 46 consecutive patients with chronic back pain admitted over a 6 month period to a 5-day inpatient rehabilitation programme. A lumbar epidural catheter was inserted and bupivacaine 0.125% was infused at a rate that produced analgesia without sensory or motor deficit over a period of 5 days. An intensive mobilizing physiotherapy programme was instituted. Physical and psychological parameters were measured on day 1, after 1 week, after 1 month and after 1 year. RESULTS: Time to complete a 50 m walk, time from sitting to standing, and spinal flexion were improved at 1 week and 1 month, but only time to complete the walk remained improved at 1 year. In Goldberg's General Health Questionnaire 28 scores were improved for social dysfunction, somatic symptoms, anxiety and insomnia, and depression, at 1 week and 1 month but only social dysfunction remained improved at 1 year. Using a Visual Analogue Scale pain ratings were unaltered after 1 year. CONCLUSION: Continuous 5 day epidural analgesia combined with intensive physiotherapy may offer a means of initial rehabilitation of chronic low back pain. The initial benefit was most marked at 1 week, with benefit still evident after 1 month. However, the benefit decreased with time. This technique may be of value as part of a more comprehensive programme of physical and psychological rehabilitation.     

Spinal epidural abscess--a case report

Despite modern medical advances, the morbidity and mortality rates associated with spinal epidural abscess remain significant, and the diagnosis is elusive. The incidence of spinal epidural abscess is approximately one to two cases per 10,000 among all patients admitted to hospitals. The symptoms of spinal epidural abscess are varied but include lower back pain, fever, local tenderness and neurological deficit especially in such high risk groups as patients with diabetes, intravenous drug abuse, chronic renal failure, alcoholism, liver disease and immunocompromization. Accumulation of data is difficult in that many physicians will never see a case during their careers. Herein, we present a case with lower back pain associated with both lower legs weakness. His abdomenon CT revealed retroperitonium and right perirenal abscess. External drainage as well as antibiotic treatment was done immediately. However, the lower legs weakness became severe and a lumbar spine MRI revealed T11-L4 epidural abscesses and L2-3 intervertebral space pus formation. Then, the patient was transfered to our Neurosurgical Ward for further treatment. His postoperative condition improved in both lower legs. This case report is to enhance the recognition and treatment of spinal epidural abscess, a rare affliction.     

Oral anticoagulant prophylaxis and epidural catheter removal

BACKGROUND AND OBJECTIVES: The use of regional anesthesia in patients receiving anticoagulants is controversial. The purpose of this review is to document the incidence of neurologic complications with insertion and removal of an epidural catheter in patients receiving oral anticoagulants and antiplatelet medication. METHODS: A retrospective review was made of the charts of 459 patients who underwent hip pinning or hip or knee replacement under regional anesthesia and received postoperative epidural analgesia and warfarin thromboembolism prophylaxis. The number of patients receiving preoperative antiplatelet therapy and warfarin, as well as baseline coagulation parameters, was documented. For patients who had postoperative epidural analgesia, the prothrombin time on the day of epidural catheter removal was obtained. Neurologic complications during the hospital stay were noted. RESULTS: Spinal anesthesia was administered to 47 patients and epidural anesthesia and postoperative analgesia to 412. Before surgery, antiplatelet therapy was given to 270 and warfarin to 180 patients, with some patients receiving both. The mean +/- SD preoperative prothrombin and partial thromboplastin times were 10.8 +/- 1.2 seconds (normal, 9.6-11.1 seconds) and 27.5 +/- 3.5 seconds (normal, 24.6-33.2 seconds), respectively. Blood on needle or catheter insertion was noted in 21 patients, all of whom were taking antiplatelet medication and/or warfarin. Epidural catheters remained postoperatively for a mean of 43.6 +/- 12.5 hours (range 5-118 hours). The mean prothrombin time on the day of epidural catheter removal was 14.1 +/- 3.2 seconds. Four postoperative peripheral neuropathies were detected. There was no clinical evidence of spinal hematoma in any patient. CONCLUSIONS: Epidural catheter placement and removal in patients taking oral anticoagulants appears to be safe. Careful monitoring of the patient for evidence of spinal hematoma after epidural catheter removal is recommended.     

Laparoscopic cholecystectomy under epidural anesthesia in patients with chronic respiratory disease

BACKGROUND: Laparoscopic cholecystectomy (LC) has become firmly established as a procedure of choice for gallstone disease. The procedure usually necessitates general anaesthesia and endotracheal intubation to prevent aspiration and respiratory embarrassment secondary to the induction of pneumoperitoneum. There is a paucity of data in the literature on the procedure being performed under regional (epidural) anaesthesia, especially in patients with coexisting pulmonary disease and pregnancy, who are deemed high risk for general anaesthesia. We report our preliminary experience with LC using epidural anaesthesia in patients with chronic obstructive pulmonary disease (COPD). METHODS: We performed LC in six patients (one man and five women), with a median age of 56 years (range, 38-74), under epidural anaesthesia over an 8-month period. All patients were ASA grade III/IV and the mean FEB1/FVC was 0.52 (range, 0.4-0.68), due to chronic asthma (two cases) and COPD (four cases). They were admitted a day prior to surgery for pulmonary function tests, nebulisers, and chest physiotherapy. An epidural catheter was introduced at T10/11 intervertebral space, and a bolus of 0.5% Bupivacaine was administered. Depending on the patient's pain threshold and the segmental level of analgesia achieved, incremental doses of 2 ml of 0.5% Bupivacaine along with boluses of intravenous 100 mcg Alfentanil was given to each patient. The patients were breathing spontaneously. No nasogastric tube was inserted, and a low-pressure (10 mmHg) pneumoperitoneum was created. LC was performed according to the standard technique. RESULTS: All the patients tolerated the procedure well and made an uneventful postoperative recovery. Median operating time was 50 min; average length of hospital stay was 2.5 days (range, 2-4). The epidural catheter was removed the morning after the operation. Only one patient required postoperative opioid analgesia. Two patients complained of persistent shoulder tip pain during surgery and required intraoperative analgesia (Alfentanil). There was no change in the patient's cardiorespiratory status, including PO2 and pCO2, and no complications occurred either intra- or postoperatively. CONCLUSIONS: LC can be performed safely under epidural anaesthesia in patients with severe COPD. Intraoperative shoulder tip or abdominal pain does not seem to be a major deterrent and can be effectively controlled with small doses of opioid analgesia.     

Treatment of incomplete analgesia after placement of an epidural catheter and administration of local anesthetic for women in labor

BACKGROUND: Approximately 15% of women still have pain after placement of an epidural catheter and administration of local anesthetic for labor analgesia. Two techniques frequently used to treat this pain were compared: (1) withdrawal of the catheter 1 cm and repeated dosing with additional local anesthetic, and (2) repeated dosing with additional local anesthetic without any catheter manipulation. METHODS: Fifteen minutes after placement of a multiple-orifice epidural catheter 5 cm into the epidural space and administration of 13 ml 0.25% bupivacaine to the parturient in labor, the adequacy of analgesia was assessed. All women who had incomplete analgesia were randomized (first intervention) to receive an additional 5 ml 0.25% bupivacaine (local-anestheticonly group) or to receive 5 ml 0.25% bupivacaine after first withdrawing the epidural catheter 1 cm (catheter-manipulation group). If after 15 min the woman still had pain, then (second intervention) the catheter was withdrawn 1 cm and an additional 5 ml 0.25% bupivacaine was administered to the local-anesthetic-only group, whereas 5 ml 0.25% bupivacaine was given to the catheter-manipulation group without further catheter manipulation. The success rate of the second intervention was assessed 15 min later. RESULTS: Seventy-eight women were enrolled in the study, 39 to each group. In the local-anesthetic-only group, 29 (74%) women were successfully treated with the first intervention and the remaining 10 (100%) were successfully treated with the second intervention. In the catheter-manipulation group, 30 (77%) were successfully treated with the first intervention and 7 (100%; 2 patients were not studied because of investigator error) were successfully treated with the second intervention (P=NS). CONCLUSIONS: Administration of additional local anesthetic without first withdrawing the epidural catheter will effectively treat most women for whom analgesia is incomplete after the placement of an epidural catheter during labor.     

Long-term epidural analgesia for pregnancy-induced intercostal neuralgia

Intercostal neuralgia is one of many possible neurological disorders associated with pregnancy. A woman presented in the 34th week of her 4th pregnancy with progressing right-sided pain and hypoesthesia in the ribs, right upper quadrant of the abdomen, and mid-thoracic area of her back. With a clinical diagnosis of pregnancy-related intercostal neuralgia, we inserted an epidural catheter at T8 for ambulatory pain management. A continuous infusion of bupivacaine was titrated by concentration and rate until adequate analgesia was obtained. The final effective dose consisted of 0.125% bupivacaine at 6 ml/h with a patient-controlled bolus dose of 2 ml every 30 min as needed (4-6 boluses per 24-h period). This allowed the patient to continue to work full-time and perform daily activities with minimal discomfort. The epidural infusion was continued until the patient went into spontaneous labor 28 days after the initial clinical visit. A full-term infant was delivered without incident. No major complications occurred such as local anesthetic toxicity, hypotension, motor weakness, or infection. Minor complications included disconnection of the catheter cap and accidental dislodgment, which required placement of a second epidural catheter. For this patient, an appropriately placed chronic epidural catheter and a titrated continuous infusion of bupivacaine provided adequate and safe analgesia for pregnancy-associated intercostal neuralgia.     

Temporary antibiotic-loaded cemented prosthesis for two-stage septic hip arthroplasty

BACKGROUND AND OBJECTIVES: Myofascial pain is the leading cause of chronic low back pain and in most cases can be successfully resolved with trigger point injections of local anesthetics. This type of pain can exist during pregnancy and exceed the analgesia provided by an epidural for labor. METHODS: A 31-year-old primiparous woman received an epidural infusion for labor analgesia. Despite complete resolution of labor pain and a solid, bilateral T10 block, the patient reported discomfort at two discrete locations in her right lumbar paraspinous muscle. RESULTS: The administration of local anesthetic via trigger point injections resulted in successful palliation of the myofascial pain. CONCLUSIONS: Myofascial pain can be an etiology of back pain in the parturient. Trigger point injections, even when used concomitantly with a functioning epidural infusion, can be a valuable aid for the provision of complete analgesia.     

Usefulness of radiologic monitoring of epidural catheters using epidurography

INTRODUCTION: Peridural analgesia involves a segmental block which at the thoracic level allows for early pulmonary recovery after chest or high abdominal surgery. The approach is difficult in children for reasons related to anatomy, maintenance, insertion of the catheter and dosing. OBJECTIVE: To report the radiologic monitoring of epidural catheter placement by epidurography as a technique for placing the epidural catheter in 17 patients for whom postoperative analgesia was to be provided by the same route. PATIENTS AND METHODS: Eighteen children (aged from 2 to 12) were given general anesthesia followed by epidural anesthesia. After catheterization of the epidural space, 1 or 1-5 ml of contrast was injected. Immediately afterwards an X-ray of the thoracic or lumbar spinal column, as appropriate to each case, was obtained. Epidural analgesia was provided with a mixture of bupivacaine 0.125% and fentanyl, in continuous perfusion or in fractionated doses. RESULTS: Placement of the catheter tip was confirmed in 17 cases by visualization of symmetry and the presence of contrast medium in the epidural space. In one case we observed extravasation of contrast medium, which had invaded the paravertebral space. The course was linear in 17 cases, with no looping. No complications related to injection of contrast medium were observed. CONCLUSIONS: Epidurography provides objective monitoring of tip placement and trajectory of epidural catheters, advantages which argue in favor of more frequent application of this imaging technique.     

Influence of anesthetic technique in postoperative analgesia in thoracic surgery

OBJECTIVE: To compare the intensity of postoperative pain after thoracotomy with 2 anesthetic techniques: 1) thoracic epidural block with bupivacaine administered before surgery (combined anesthesia with isoflurane) and 2) conventional balanced anesthesia with isoflurane and endovenous fentanyl. PATIENTS AND METHODS: Thirty patients scheduled for thoracotomy by lateral incision (T5-T6) were randomly divided into 2 groups of 15. Group A received 8 ml of 0.5% bupivacaine with adrenalin 1:200.000 30 min before start of surgery while group B received 8 ml saline solution through an epidural catheter inserted to T4-T8. Combined anesthesia (4 ml 0.5% bupivacaine through an epidural catheter 150 min after the first dose and isoflurane in 100% oxygen) was used in group A. Group B received balanced anesthesia with endovenous fentanyl 2.5 micrograms/kg and isoflurane in 100% oxygen. The difference in pain intensity during postoperative recovery was assessed by way of the following variables: number of boluses administered by epidural patient-controlled analgesia (bupivacaine 0.0625% and fentanyl 6 micrograms/ml); score on a visual analog scale of 10 at baseline and at 1, 3, 7, 11, 19 and 43 hours after surgery; and need for additional analgesia (diclofenac) during the 43 hours of study. Arterial gases were measured during the preoperative period and at 1, 3, 7, 19 and 43 hours after surgery. RESULTS: No significant differences in pain intensity measured on the visual analog scale, by the number of boluses per patients or by need for additional analgesia were found between the 2 groups. The total number of boluses administered and additional analgesic requirements were greater in the group receiving bupivacaine, although the difference was not significant (p = 0.095 and p = 0.056, respectively). Nor were there significant differences in pH and PaCO2 levels for the 2 groups. CONCLUSIONS: Analgesic efficacy after thoracotomy was similar for our 2 groups receiving either combined anesthesia (epidural bupivacaine at 0.5% and isoflurane) or balanced anesthesia with isoflurane and endovenous fentanyl.     

Equilibrium analysis of high affinity interactions using BIACORE

Both asymmetrical sensory blockade and dural puncture are undesirable outcomes of epidural analgesia. Identifying the epidural space with the needle bevel oriented parallel to the longitudinal axis of the patient's back limits the risk of headache in the event of dural puncture. However, rotating the bevel to direct a catheter cephalad may risk dural puncture. We prospectively studied the effects of needle rotation on the success of labor epidural analgesia and on the incidence of dural puncture. One hundred sixty ASA physical status I or II laboring parturients were randomly assigned to one of four groups. The epidural space was identified with the bevel of an 18-gauge Hustead needle directed to the patient's left. It was then rotated as follows: Group 0 = no rotation, final bevel orientation left (n = 39); Group 90 = rotation 90 degrees clockwise, bevel cephalad (n = 43); Group 180 = rotation 180 degrees clockwise, bevel right (n = 36); Group 270 = rotation 270 degrees clockwise, bevel caudad (n = 42). A single-orifice catheter was inserted 3 cm, and analgesia was induced in a standardized fashion. Dural puncture was evenly distributed among the groups (4.4%). There were more dermatomal segments blocked, fewer one-sided blocks, and more patients comfortable at 30 min with the needle bevel directed cephalad. Using a catheter inserted through a needle oriented in the cephalad direction increases the success of epidural analgesia. Implications: This prospective study shows that an epidural catheter inserted through a needle oriented in the cephalad direction increases the success of labor analgesia in the parturient. Carefully rotating the needle cephalad does not increase the risk of dural puncture, intravascular catheters, or failed blocks.     

Drug-induced gingival hyperplasia and its management--a literature review

The purpose of our study was to find out whether patient-controlled epidural administration (PCEA) of a mixture containing a low-dose local anaesthetic, opioid and alpha 2-agonist provides as good or better postoperative analgesia as continuous epidural administration of the same analgetic solution. METHODS: 30 patients (ASA I-III), scheduled for major abdominal surgery, were randomly divided into 2 groups. 90 minutes after induction of general anaesthesia all patients received a continuous epidural infusion of 5 ml/h of the analgetic solution (50 micrograms sufentanil + 150 micrograms clonidine in 50 ml 0.125% bupivacaine) until the end of surgery. Immediately postoperatively the patients of group A received a continuous infusion of the study solution (5-8 ml/h), the patients of group B received a baseline continuous epidural infusion (3 ml/h), additionally they could self-administer 5 ml boli via a PCEA device. Measurements included the total dose of infused drug solution, pain at rest and on exercise by a visual analogue scale, cardiorespiratory data and side effects within the first 24 hours postoperatively. A standardised interview on analgesia and side effects was held 2 days after surgery. RESULTS: The PCEA group demanded less epidural analgesics (gr. B: 112 +/- 33 ml vs. gr. A: 135 +/- 20 ml) p < 0.01). Both continuous epidural infusion and patient-controlled administration provided very good analgesia at rest (gr. A: VAS 0.4 +/- 0.4 and gr. B: VAS 0.4 +/- 0.5) (n.s.). On exercise continuous epidural infusion of analgesics resulted in significantly lower pain scores (gr. A: 1.9 +/- 1.1) than patient-controlled application (gr. B: 3.4 +/- 1.1) (p < 0.01). We did not notice severe side effects such as respiratory depression or drop of heart rate or blood pressure. CONCLUSION: In patients at rest both continuous and patient-controlled epidural administration of analgesics provides excellent analgesia after major abdominal surgery. Contrariwise, patients on exercise who could use a PCA-device experienced more pain compared to those with a continuous epidural infusion technique. On the other hand the patients of the PCA-group consumed less epidural analgesics. We did not notice any severe side effects such as respiratory depression or cardiovascular instability during the study.     

Epiduritis after long-term pain therapy with an epidural catheter--review of the literature with a current case report

Patients suffering from vascular disease are often a challenge for the acute pain service. Ischaemia, impaired wound healing, stump and phantom limb pain often require a complex analgesic regimen. Invasive measures such as spinal or epidural catheters can be very helpful but carry the risk of infection, as shown by this case report. A 53-year-old woman with a ten-year history of diabetes developed arterial vascular disease. Her right lower leg had been amputated two years previously. She was now admitted with necroses of the left forefoot. A bypass operation was performed under general anaesthesia. Because of intractable ischaemic pain, she was provided with an epidural catheter by the acute pain service. The bypass occluded, however, and a few days later her left lower leg also had to be amputated, this operation being performed under epidural anaesthesia with bupivacaine. The catheter was subsequently used for postoperative pain control and as a means to prevent phantom limb pain. When signs of superficial catheter infection were noticed days later, the catheter was immediately removed. Intractable pain then developed in the left leg which could not be sufficiently controlled with opioids and NSAIDs, and so a second epidural catheter was inserted one segment rostrally. Several days later the infected vascular prosthesis had to be removed followed by amputation of the thigh, this operation also being performed in epidural anaesthesia. Eleven days after insertion of the first epidural catheter, the patient complained of low back pain and headache. Examination by a neurologist revealed no signs of intraspinal infection. The second epidural catheter dislocated at this point in time and it was decided to introduce a third one, this being the only means to treat the otherwise intractable stump pain. Ten days later meningism, Kernig's sign and leucocytosis developed. NMR tomography detected intraspinal fluid in the epidural space at the dorsal border of the spinal canal. A hemilaminectomy was performed. The spinal epidural space showed signs of inflammation of the adipose tissue, but no pus. A little necrotic material and residues of an old haematoma were removed and the epidural space was lavaged. Specimens taken from the epidural material revealed colonisation with staphylococcus epidermidis, which was sensitive to the broad spectrum antibiotics formerly given to the patient to treat the infection in the left stump. By the next day, all signs of epiduritis had disappeared and the patient recovered completely.     

Extradural catheter-related infections in patients with infected cutaneous wounds

We report three previously healthy individuals, aged 19-40 yr, with co-existing infected lower limb cutaneous wounds, who developed, in all probability, spinal space infections complicating continuous extradural analgesia. As the number of patients with extradural catheters and large cutaneous wounds represents a small fraction of the total number of patients with extradural catheters, three cases of presumed spinal space infection over a 4-yr period suggests that extradural analgesia with a catheter technique in this clinical situation is unsafe.     

Noninvasive evaluation of myocardial ischemia in Kawasaki disease: comparison between dipyridamole stress thallium imaging and exercise stress testing

PURPOSE: Reduction of the frequency of injections and localization of the absorption of drug molecules to the injection site would be of great advantage in epidural pain treatment. The epidural use of a controlled release gel of lidocaine and ibuprofen was studied. METHODS: The effect of a poloxamer gel (25%) containing 2% lidocaine.HCl and 2% ibuprofen.Na on the duration of analgesia after epidural administration to pigs was compared with drug in solution. Analgesia was assessed by observing the motor function and the nociceptive reflex-withdrawal response to painful pressure stimulation on the feet. Pharmacokinetic and histological examinations were performed. RESULTS: Analgesia lasted significantly longer after epidural lidocaine gel injection in comparison with the solution. The gel prolonged the systemic absorption, thereby increasing the epidural availability of lidocaine for spinal analgesia. Although the absorption of ibuprofen was prolonged after epidural gel injection, the duration of analgesia as compared with the solution was not prolonged. After epidural injection, only slight inflammatory changes were observed in the tissue structures of the epidural space, but none in the spinal cord. CONCLUSIONS: These results demonstrate poloxamer gel to be a promising controlled-release, injectable epidural formulation for the management of pain.