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• W1978218602 abstract "We report a case of transient neurological impairment following the use of air to detect loss of resistance during placement of an epidural catheter for labour analgesia. A 29-year-old Asian female, primagravida presented to the delivery suite in labour at 39 weeks gestation having had an uneventful antenatal period. Her uterine contractions were of moderate intensity, palpable every 4 min, with a foetal heart rate of 140 beat.min−1 without any decelerations. Pelvic examination revealed an effaced cervix, 2–3 cm dilated, with a cephalic presentation at minus 2 station. Intramuscular pethidine was used for relief of labour pain after artificial rupture of the membranes. After the start of an oxytocin infusion, the patient requested epidural analgesia. Following a full explanation of the risks and benefits, the epidural was attempted with the patient in the sitting position using a 16G Tuohy needle at the L3–4 space and an air-filled syringe to detect the loss of resistance. The first attempt was unsuccessful so a second attempt was carried out using the same space. Despite difficulties, the epidural space was eventually located using approximately 10 ml of air. The catheter was then advanced about 4 cm into the epidural space. Neither cerebrospinal fluid nor blood could be aspirated from the epidural catheter. Following a test dose of 2 ml of lidocaine 2% with 1 : 200 000 epinephrine, a bolus of 20 ml of a mixture bupivacaine 0.1% and fentanyl 2 µg.ml−1 was injected into the catheter. This was followed by a continuous infusion at 10 ml.h−1. After 20 min, pain relief was unsatisfactory despite withdrawal of the catheter by 1 cm and repeated bolus doses of 10 ml bupivacaine 0.25%. The epidural catheter was therefore re-sited for the third time at the L1–2 space using 3 ml of air from a 10-ml air filled syringe to detect loss of resistance. Good analgesia was achieved with this attempt providing a sensory level of block up to T7. Normal delivery occurred 6 h later. Following this, the epidural catheter was removed prior to discharge to the postnatal ward. The following day, the patient complained of numbness in her right buttock and foot. Neurological examination revealed multiple areas of altered sensation over the right buttock and lateral aspect of the right calf corresponding to dermatomes L4/5. There was no motor weakness with intact deep tendon reflexes. Perineal sensations were present with a normal rectal sphincter tone. Computed tomograph (CT) scans showed a low absorption image consistent with the presence of gas in the epidural space. EMG revealed no conduction disturbance. On day 4, sensations started to return on the lateral aspect of the patient's right leg and there was complete neurological recovery over the right buttock and thigh within the proceeding 5 days. We consider that the air injected into the epidural space may have been responsible for the neurological symptoms experienced by the patient. The return of sensation after 4 days suggests that air pockets in the epidural space take a few days to absorb into the blood stream. There was no other apparent cause for this neurological deficit. This iatrogenic problem could have been potentially avoided by using saline instead of air to detect loss of resistance. Various neurological deficits caused by air in the epidural space have been reported including acute nerve root compression [1], chronic radiculopathy [2] and cauda equina syndrome [3]. There is therefore a risk of inflicting a neurological deficit following the use of air to detect the epidural space, which can potentially lead to protracted investigations to exclude any neural damage and a prolonged hospital stay. This sort of complication might be occurring more frequently than is reported and it is our firm belief that air should no longer be used during epidural catheter placement. However, anaesthetists who continue the practice of injecting air for the identification of the epidural space should be aware of this and associated complications." @default.
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• W1978218602 title "Air in the epidural space leading to a neurological deficit" @default.
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• W1978218602 doi "https://doi.org/10.1046/j.1365-2044.2003.306721.x" @default.
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