Epidural covering something bad

[intubator]

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I know there used to be (not much anymore) controversy about epidurals covering up a uterine rupture.

There is currently a controversy about regional or neuraxial in ortho stuff covering up posible compartment syndrome post-op.

However, I think I have a case were my epidural delayed recognition of a post-op peritonitis (bowel perforation or it might have been a suture line unraveling). I want to write it up. I have done what I think is a pretty thorough search of the literature and could only find one case report in a post-op CABG patient where they think the epidural covered up an acute abdomen (who does epidurals for CABG's anyway?). But I suck at literature searches.

Has anyone heard of this or know of any articles addressing the issue or similar topic?

 

[coprolalia]

Write it up! Sounds like a good case. Makes sense in theory about cases of abdominal compartment syndrome being "hidden" by an epidural, but where this is suspected they usually use tension sutures (after ex-lap) and measure bladder pressures. There aren't many cases where you're going to put an epidural in such a patient, though, as most of the time it's from traumatic injury or the like. Peritonits, though, is a different animal. Make sure that you covered all your bases before you submit your case report (e.g., was the patient tachy, febrile, etc.).

-copro

 

[Gator05]

I seem to recall case reports for peripheral compartment syndrome and regional anesthesia. Basically, if the patient is completely numb with motor block, this is possible. We usually aim for analgesia/some anesthesia, and there have also been case reports (I think personal communication) of compartmental pain breaking through the block. Think of tourniquet pain under regional; doesn't matter how good the block is, the ischemic humors are gonna hurt.

As for peritonitis, I'd have a hard time believing the epidural completely masked the pain. Due to the visceral nature, you'd have to have a very high, dense block. How did they eventually discover the peritonitis? What type of pain did the patient have? How well setup was the block throughout the perioperative course?

 

[Dejavu]

Are you sure this isn't one of those "it's anesthesia's fault" deals where the surgeons should have picked up on the patient's condition earlier and are blaming you.

Recently a pt told me that he had had a complication from anesthesia a few years ago. It seems that he had a 4 x 6 inch burn on his thigh (about where the cautery pad goes) and his surgeon told him that it was from "anesthesia gas migrating down under the drapes during the case, causing the burn."

True story.

 

[Noyac]

I fine it very unlikely that the epidural would have masked the acute abdomen that well.

 

[snowman8]

I recently performed a literature search on medline looking for an association with postoperative analgesic techniques and masking postoperative compartment syndrome of the lower extremity. All I found were several case reports. These case reports included IV PCA, Epidural catheters (with local anesthetic and narcotic infusion), and peripheral nerve block. There were several cases attributing a delay to all the above techniques and several cases saying that a regional technique did not lead to a delay in the diagnosis. Some of the conclusions that I came to were

1. IV PCA with narcotics can mask compartment syndrome (relative risk compared to regional unknown)
2. When diagnosing compartment syndrome the classic "pain out of proportion to exam" is not always the first sign and others signs such as numbness and weakness from an ischemic neuropathy should be sought out and not confused with effects from a regional technique. Several authors that claimed that a regional technique masked the diagnosis did not understand the pharmacology and applied physiology of regional anesthesia and misattributed the numbness or weakness from an ischemic neuropathy to the effects of an epidural and delayed the diagnosis b/c of their lack of knowledge.
3. If using a regional technique use dilute concentrations of local anesthetic in combination with neuroaxial narcotics to decrease the risk of motor block and chance of masking the pain associated with compartment syndrome.

In my opinion if you think regional anesthesia benefits the patient you should use it, otherwise you should be using IV PCA to control postop pain. There is no evidence which technique attributes to a higher incidence of masking postoperative compartment syndrome.

I'm actually presenting this abstract at ASRA in Cancun in a month if anyone else will be there.

 

[Jeff05]

peritonitis presents with fever, tachycardia, elevated WBC, hypotension and lots of other stuff. rigidity is only found in about half of pts with peritonitis.


why would this patient have a spontaneous perf? it is exceedingly more likely that the suture line did not hold. it's an expected complication.

but, could an epidural DELAY diagnosis? perhaps.

 

[intubator]

I fine it very unlikely that the epidural would have masked the acute abdomen that well.

I agree mostly. The truth is, I need to go back and read the guys chart because it was a few months ago and it seems like he was never really that comfortable. He wasn't in severe pain, but I remember increasing the rate, then going from 0.05% to 0.1% bupivicaine to try to make him more comfortable - so it isn't like he was completely comfortable. I just wonder if he hadn't of had the epidural if the diagnosis would have been made sooner.

I have read most of the articles on compartment syndrome stuff and also a bunch on the OB literature and uterine rupture. I get the feeling that epidurals don't make things worse, any more than what a PCA would do. Interesting enough, there are studies that show (some of them in cute little beagle dogs) that epidurals actually improve outcomes with abdominal sepsis and improve perfussion markers, etc.

I certainly wouldn't change practice of using an epidural when I think it is going to be beneficial (based on this one case), but I think it is an interesting topic worth discussing and investigating further because safer and perhaps just as effective techniques are available, such as paravetebral single shots or catheters (See BladeMD's discussion in the Anesthesia Club on paraveterbral blocks) or continuous wound infusion, which has recently been shown to be a very effective way to control post-op wound pain.

Continuous Preperitoneal Infusion of Ropivacaine Provides Effective Analgesia and Accelerates Recovery after Colorectal Surgery: A Randomized, Double-blind, Placebo-controlled Study.

Pain and Regional Anesthesia
Anesthesiology. 107(3):461-468, September 2007.
http://www.anesthesiology.org/pt/re...9kkdn22ytTTwh9J2W!923867264!181195629!8091!-1

I'm actually presenting this abstract at ASRA in Cancun in a month if anyone else will be there.

Hey, I'll be there too. I'll look for your abstract. I am presenting a cool case report also. My name on the paper won't be intubator though. 🙂

 

[Antibiotix2006]

We had a problem with the epidural masking an external Iliac thrombus in a post op sigmoid neo bladder for Ca bladder recently. Suspicion came on when the patient started complaining of pain in his Rt LL while on epidural infusion about 12 hours post op. The only sign at that point was a rash on his thigh. 1 hr after stopping the infusion his limb started going ischemic. Doppler found a thrombus and he was opened up again.

 

[Noyac]

We had a problem with the epidural masking an external Iliac thrombus in a post op sigmoid neo bladder for Ca bladder recently. Suspicion came on when the patient started complaining of pain in his Rt LL while on epidural infusion about 12 hours post op. The only sign at that point was a rash on his thigh. 1 hr after stopping the infusion his limb started going ischemic. Doppler found a thrombus and he was opened up again.

Would the outcome have been any different had the pt had a PCA instead?

 

[Antibiotix2006]

I'm wondering if any vasodilation caused by the epidural contributed to keeping his limb going for a while longer. The reason being the rapid deterioration to ischemia soon after stopping the epidural. Probably just coincidental, but just a thought. We were using a bupivacaine + fentanyl infusion.


Apart from the rash and mild parasthesia, he did not show anything very typical suggesting limb ischemia. I believe that he may have presented differently if he was on a PCA allowing us to pick up the problem earlier.