Radicular acute pain after epidural anaesthesia with the technique of loss of resistance with normal saline solution

Abstract

SummaryFatal oesophageal perforation occurred as a complication of elective general anaesthesia for cataract extraction in a 77-year-old female patient. Tracheal intubation had been achieved, albeit with difficulty, in the course of a clinical trial of the intubating laryngeal mask.Keywords Equipment; intubating laryngeal mask. Complications. ...................................................................................... Correspondence to: Dr M. A. Branthwaite Accepted: 30 May 1998 The laryngeal mask has found a useful place in anaesthetic practice both within and outside the hospital environment. A modified system, the intubating laryngeal mask, has been introduced recently to facilitate endotracheal intubation and a fatality resulting from its use is reported here. Case historyA 77-year-old female patient, ASA II, was scheduled for elective cataract extraction under general anaesthesia. Contralateral cataract extraction had been carried out uneventfully 8 months earlier under general anaesthesia involving controlled ventilation delivered through a size 4 laryngeal mask.On the evening before surgery, the patient consented orally to participate in a proposed trial of the intubating laryngeal mask. She received no written information about the trial and a designated consent form for participation was neither offered nor signed. A protocol for trial of a prototype intubating laryngeal mask had been cleared by the hospital Ethics Committee 3 years previously but had been deferred pending inclusion of the hospital in a multicentre trial of the definitive model. A draft protocol for the multicentre trial differed in a number of respects, most notably that it permitted a maximum of five attempts at intubation instead of two as proposed initially. The revised protocol had not been submitted to the local Ethics Committee.On the day of surgery, the patient was one of several on whom the technique of intubation through the definitive model of the intubating laryngeal mask was demonstrated. Difficulty was encountered in intubation, the mask was replaced at least once and intubation was only achieved successfully on the fifth attempt. Oesophageal intubation was suspected on the unsuccessful attempts. Blood was aspirated from the pharynx after intubation and a nasogastric tube, passed without difficulty to decompress the stomach, confirmed the presence of bleeding.Once awake, the patient complained of pain in the back and crepitus was noted in the neck. A chest X-ray about 3 h postoperatively showed air in the soft tissues and both sides of the mediastinum. There was a small effusion at the right base and some plate atelectasis at the left base. Oesophageal rupture was confirmed radiologically using a dilute solution of barium. The report described a fairly large oesophageal pouch arising from the posterior wall with a small amount of barium passing through a fistulous opening situated just below the neck of the pouch.A policy of conservative management was adopted but the patient's condition gave rise to increas...

A Retrospective Effectiveness Study of Loss of Resistance to Air or Saline for Identification of the Epidural Space

“…Moreover, at least some of these complications have been reported after LOR to saline. 16 We did find a small but statistically significant increase in the number of attempts required to locate the epidural space with LOR to air compared with saline. There are several possible explanations.…”

Motor Weakness after Caudal Epidural Injection Using the Air-acceptance Test

“…Epidural air can spread along the nerves of the paravertebral space, and, depending on its location, neurologic complications such as multiradicular syndrome, lumbar root compression, and even paraplegia can occur [7,8]. Kennedy et al [8] reported a case of back pain and paraplegia due to an erroneous injection of massive air in the epidural space during continuous lumbar epidural infusion of opioids and local anesthetics to treat cancer pain.…”

Symptomatic Pneumorrhachis

“…The most common etiology in these symptomatic cases was diagnostic or anesthetic intervention to the spine (n ¼ 8). 18,[30][31][32][33][34][35][36] Neurologic symptoms in four patients were associated with pneumothorax or pneumomediastinum caused by thorax trauma and lobectomy for small-cell carcinoma of the lung. 20,[37][38][39] Two patients' neurologic symptoms were associated with pneumocephalus caused by head trauma and a suboccipital craniotomy for foramen magnum meningioma, respectively.…”

“…Recent studies have shown that PR itself can cause neurologic symptoms ranging from radicular pain to cauda equina syndrome. [30][31][32][33][34][35] A literature search disclosed 19 cases in which the patient exhibited one or more symptoms. Of these 19 patients, 10 presented with weakness, 7 with sensory loss, and 7 with radicular pain (►Table 1).…”