NM-348
Intrathecal Migration of Functioning Epidural Catheter following Fetoscopic Myelomeningocele Repair: A Case Report
Sutton C, Aina T
Texas Children's Hospital, Houston, TX, USA
Intro:
The spontaneous migration of a previously functioning epidural catheter into the intrathecal space is extremely rare, with just a few reports in the literature.(1,2) We present a case of postoperative migration of an epidural catheter to the intrathecal space after fetoscopic myelomeningocele repair. To our knowledge, this is the first report of postoperative intrathecal migration of an epidural catheter without known dural puncture.
Case:
A 28 yo G2P0 at 24w2d gestation presented for evaluation for prenatal repair of fetal myeloschisis. The fetus was noted to have an open neural tube defect from L1 through the lower sacrum, with Chiari II malformation but preserved lower extremity movement. No other fetal defects were found, and the mother was otherwise healthy. After thorough informed consent involving maternal-fetal medicine, pediatric neurosurgery, and pediatric anesthesiology, the decision was made to proceed with fetoscopic myelomeningocele repair.
On the day of surgery, a lumbar epidural was placed for postoperative analgesia with negative test dose. Once in the operating room, she moved herself to the operating table easily. General endotracheal anesthesia was induced, and the surgery was completed uneventfully. The epidural was then bolused with a total of 15mL 0.25% bupivacaine in divided doses after negative aspiration. An infusion of 0.1% bupivacaine with 10mcg/mL fentanyl was started at 10mL/hr to achieve analgesia for both mother and fetus. The patient was extubated and taken to the labor and delivery unit for recovery. At the time of transfer, she had normal vital signs, minimal lower extremity motor blockade, and no pain.
Approximately 2 hours later, decreased variability and late decelerations were noted on the fetal heart rate tracing. The epidural infusion was paused during evaluation due to a marginally lower than baseline maternal systolic blood pressure (SBP) in upper 80s. After repositioning to a full lateral position and administration of terbutaline, decelerations ceased and variability improved. However, hypotension with SBP in the 70s continued, and markedly increased density of motor blockade was noted. Upon aspiration of the epidural catheter, free-flowing clear CSF was seen. The epidural catheter was removed. Once the block receded, bilateral TAP blocks were performed, and the patient transitioned easily to an oral pain regimen the following day. She did not develop headache, and was discharged once uterine quiescence was confirmed.
Discussion:
Epidural catheters, particularly the stiff plastic variety, can migrate out of the epidural space even after a catheter has been functioning appropriately.(3,4) Though it is an exceedingly rare complication after demonstration of normal epidural catheter function, anesthesiologists should have a high index of suspicion of intrathecal catheter in any patient with unexplained hypotension or acute increase in density of motor blockade. Early identification of intrathecal catheter migration can prevent serious adverse events for both mother and fetus undergoing fetal surgery.
1. A&A Case Reports. Epub 2017.
2. Minerva Anest. 2012:78;858.
3. Int J Obstet Anesth. 2004;13:227–233.
4. Kaohsiung J Med Sci. 2012;28(7):373-6.
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