Subject(s)
Anesthesia, Epidural , Cauda Equina , Injections, Epidural/adverse effects , Intraoperative Complications/etiology , Lidocaine , Nerve Compression Syndromes/etiology , Humans , Intraoperative Complications/physiopathology , Male , Middle Aged , Nerve Compression Syndromes/physiopathology , Subarachnoid SpaceABSTRACT
Maldistribution of local anesthetic administered through a subarachnoid catheter recently has been implicated as a possible cause of sacral root injury. To examine subarachnoid distribution of catheter-injected local anesthetic, we constructed a model of the subarachnoid space and administered solutions containing lidocaine and methylene blue through sacrally directed catheters. We studied three catheters: a 28-G endport, a 20-G endport, and a 20-G multiple sideport. To determine the injection rates to be used, ten clinicians were observed while they performed mock subarachnoid injections: the mean (+/- standard deviation) "normal" injection times for the 28-G and 20-G catheters were 52.6 +/- 17.2 and 11.9 +/- 7.2 s, respectively. The correlation coefficient for lidocaine concentration estimated by methylene blue spectrophotometric absorbance and measured by immunoassay was 0.977. Administration of hyperbaric local anesthetic through a sacrally directed catheter resulted in restricted distribution of anesthetic with a relatively high peak concentration. Rate of injection was a critical factor affecting distribution; faster injections tended to distribute solution more uniformly and to a higher segmental level, resulting in substantially lower peak concentrations. When catheters were injected at clinically relevant rates, the 28-G catheter produced the greatest degree of maldistribution; this difference appeared to be primarily a function of flow rate. Differences in peak lidocaine concentration between the two 20-G catheters were neither large nor consistent. However, despite sacral placement, the multiple-sideport catheter distributed anesthetic toward "higher" spinal segments more consistently. Distribution was more favorable when the injected solution was less dense (closer to isobaric).(ABSTRACT TRUNCATED AT 250 WORDS)
Subject(s)
Anesthesia, Spinal/instrumentation , Anesthetics, Local/pharmacokinetics , Subarachnoid Space , Anesthetics, Local/administration & dosage , Catheters, Indwelling , Humans , Injections , Models, AnatomicABSTRACT
Four cases of cauda equina syndrome occurring after continuous spinal anesthesia are reported. In all four cases, there was evidence of a focal sensory block and, to achieve adequate analgesia, a dose of local anesthetic was given that was greater than that usually administered with a single-injection technique. We postulate that the combination of maldistribution and a relatively high dose of local anesthetic resulted in neurotoxic injury. Suggestions that may reduce the potential for neurotoxicity are discussed. Use of a lower concentration and a "ceiling" or maximum dose of local anesthetic to establish the block should be considered. If maldistribution of local anesthetic is suspected (as indicated by a focal sensory block), the use of maneuvers to increase the spread of local anesthetic is recommended. If such maneuvers prove unsuccessful, the technique should be abandoned.
