A hemothorax after thoracic epidural anesthesia

Iida, Yoji; Kashimoto, Satoshi; Matsukawa, Takashi; Kumazawa, Teruo

doi:10.1016/0952-8180(94)90093-0

Cited by 24 publications

(18 citation statements)

References 5 publications

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“…As Oku and Nishimoto [7] reported, conforming to the small angle toward the midline did not prevent the advancement of the Tuohy needle toward the opposite intravertebral foramen during puncture of the ligamentum flavum. In these previous reports, misplacement of the epidural catheter occurred at the opposite side of the thoracic space [2,4,7]. In contrast, ipsilateral pleural puncture occurred in the present patient.…”

Section: Discussionsupporting

confidence: 42%

“…Koch and Nielsen [3], and Furuya et al [4] have reported the intrapleural misplacement of an epidural catheter found by surgeons during open thoracotomy. Iida et al [2] reported a patient who required chest drainage after cholecystectomy because of hemothorax and the patient's complaint of dyspnea. In these patients and ours, a "loss-ofresistance feeling" was obtained.…”

Section: Discussionmentioning

confidence: 99%

“…Pneumothorax after thoracic epidural anesthesia is a rare but possible complication [2]. We report a case of pneumothorax probably associated with epidural needle insertion.…”

Section: Introductionmentioning

confidence: 90%

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Pneumothorax associated with epidural anesthesia

Miura

Tomiyasu

Cho

et al. 2004

Journal of Anesthesia

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paramedian approach at the level of the Th 7 -Th 8 interspace. After contacting the vertebral lamina, the angle of the needle was adjusted to identify the epidural space. The Tuohy needle was directed at an angle of 45°t o cephalad, and, presumably, less than 15° toward the midline. A loss-of-resistance technique, using a salinefilled glass syringe, detected a likely space at a depth of 6 cm from the skin. A test aspiration was done with the syringe to confirm negative blood or cerebrospinal fluid, when air was aspirated unexpectedly. At that moment, the patient leaned slightly toward the resident. Although no symptom of pneumothorax, such as respiratory distress or decreased breath sounds, was observed, the needle was withdrawn. The other, experienced, anesthesiologist tried to insert the epidural needle via the left paramedian approach at the level of the Th 8 -Th 9 interspace after adjusting the patient's position, but without changing it to another position. The Tuohy needle was introduced 1.0 cm laterally from the midline. After contacting the lamina, "walking" on the lamina facilitated the loss-of-resistance feeling obtained at a depth of 6 cm from the skin. The angle of the needle was then about 45° to cephalad, and 15° toward the midline. A test dose of 3 ml of 2% lidocaine was injected from the epidural catheter. Bilateral Th 7 -Th 9 thermal hypesthesia was confirmed 5 min later with cold test. Subsequently, general anesthesia was induced with intravenous fentanyl, 100 µg; propofol, 90 mg; and vecuronium, 9 mg. To achieve left-sided one-lung ventilation during the right bullectomy, a single-lumen endotracheal tube with a bronchial blocker was intubated. Anesthesia during one-lung ventilation was maintained with sevoflurane, 70% oxygen in nitrogen and intravenous fentanyl, and appropriate oxygenation and carbon dioxide elimination were maintained. The anesthesia and operative procedure were then uneventful.A routine postoperative chest radiograph, to verify proper pulmonary expansion, was taken about 4 h after the first attempt at inserting the epidural catheter, and it

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Section: Discussionsupporting

confidence: 42%

Section: Discussionmentioning

confidence: 99%

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Pneumothorax associated with epidural anesthesia

Miura

Tomiyasu

Cho

et al. 2004

Journal of Anesthesia

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“…Hemothorax occurred after intercostal or epidural catheterization due to accidental perforation of the intercostal vein or artery [6,7]. Cases of hemothorax after the insertion of a central venous or pulmonary artery catheter have also been reported [8,9].…”

Section: Discussionmentioning

confidence: 99%

“…An anatomical study, using magnetic resonance imaging, suggested that the tip of the central venous catheter may impinge on the right atrium and perforate the atrium [10]. In patients with iatrogenic hemothorax, the development of hemothorax occurred over a longer period of time, taking several hours to several days [6,7,9,11].…”

Section: Discussionmentioning

confidence: 99%

Unanticipated hemothorax during general anesthesia

et al. 2004

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We experienced a case of uncommon spontaneous hemothorax during general anesthesia. A 72-year-old woman underwent emergency repair of damaged ascending colon. Her chest roentgenogram before surgery revealed no abnormalities. After the uneventful surgery, the trachea was extubated and the patient breathed without difficulty with stable vital signs. However, the S(p)(O)(2) varied around 95% with a 100% oxygen mask. Chest roentgenogram obtained after extubation showed a massive amount of fluid in the pleural cavity. A chest drainage tube was inserted, and approximately 1000 ml of frank blood was drawn without air leakage. Thereafter, her oxygenation remarkably improved. We could not determine the etiology of the hemothorax.

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Intercostal bleeding that developed during thoracic epidural catheterization

et al. 2008

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source of bleeding was not identifi ed, because active bleeding was not observed. At the end of the surgical procedure, we confi rmed that the hematoma was not bleeding or further enlarged (Fig. 1). The operation was performed without further complications and the patient was discharged without any neurological defi cits. In this patient, hemothorax and hematoma formation caused by the insertion of the Tuohy needle were recognized because the surgery was a VATS procedure. The multiple attempts to insert a Tuohy needle were suspected to have caused injuries to the intercostal vessels and pleural perforation [3].The intercostal artery arises from the descending thoracic aorta and divides into the anterior and posterior intercostal arteries [4]. The posterior intercostal artery subdivides into the posterior branch and the spinal branch. Together with the spinal nerve, the spinal branch enters the spinal canal via the intervertebral foramen, and subdivides into the dorsal somatic branch and the radiculomedullary artery. The radiculomedullary artery further subdivides into the anterior and posterior segmental medullary arteries, which are accompanied by the anterior and posterior nerve roots, respectively. The anterior and posterior segmental medullary arteries supply the ante rior and posterior spinal arteries. The artery of Adamkiewicz is the great anterior segmental medullary artery, the most important feeding vessel of the thoracolumbar spinal cord. The spinal-cord circulation is susceptible to intraoperative ischemic damage. Thoracic operations, such as the repair of aortic aneurysms, esophagectomy, and chest wall resection, pose a potential risk to the spinal-cord circulation. An epidural needle inserted in an inappropriate direction toward the paravertebral fringes may injure the intercostal vessels. Causes of hypoperfusion include aortic cross-clamping, rib retraction, intercostal artery interruption or compression, and costo-vertebral junctional bleeding [5]. Anesthesiologists and surgeons should be aware that bleeding from the intercostal vessels and hematoma formation can reduce or interrupt spinal blood fl ow, including that in the artery of Adamkiewicz, resulting in a serious outcome [6].In order to prevent intercostal vascular injury during a thoracic epidural insertion, anesthesiologists should picture a three-dimensional image of the neuraxial anatomy and the vertebral midline, and decide on an appropriate entry site, followed by insertion at an oblique angle toward the vertebral midline. The following precautions may also help to reduce complications: (1) avoid repeated needle insertions into a single intervertebral space; (2) avoid advancing the needle deeply; (3) ensure that the patient is in an appropriate lateral decubitus position or a sitting position, which facilitates location of the vertebral midline; (4) use a transparent drape; and (5) use a median approach if possible.

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A hemothorax after thoracic epidural anesthesia

Cited by 24 publications

References 5 publications

Pneumothorax associated with epidural anesthesia

Pneumothorax associated with epidural anesthesia

Unanticipated hemothorax during general anesthesia

Intercostal bleeding that developed during thoracic epidural catheterization

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