Epidurograms in the management of patients with long-term epidural catheters.

BACKGROUND AND OBJECTIVES: Standardized test doses have been established in the practice of anesthesiology to determine the location of the epidural catheter tip. The resulting data obtained after test dosing is open to interpretation, and comparison is difficult. A more objective method of catheter verification and epidural space measurement is indicated in long-term epidural catheterization. The goal of this review is to define a standard procedure for epidurography, explore the use of an epidurogram algorithm in differential diagnosis, and review the temporal relationship of a series of epidurograms. METHODS: A standard epidurogram procedure was defined and used for the study. Routine postoperative epidurograms were obtained following epidural catheter placement. Serial epidurograms were obtained when clinically indicated, as described in the epidurogram algorithm. Radiographs taken after injection of the dye were used for determination of epidural catheter tip location and volume dye flow. Two cases are presented to demonstrate the effectiveness of the epidurogram algorithm. RESULTS: Epidurograms show dye dispersion within the space, allowing for visualization of anomalies, resulting in a permanent record for later review. Case reports demonstrate the use of epidurograms in determining the cause of changes in epidural analgesia. CONCLUSIONS: The review of repeated epidurograms and presented case reports support the use of epidurograms as a diagnostic tool for clinical practice. Abnormal epidurograms helped determine epidural space infection, tumor obstruction, space compression from vertebral compression fractures, and epidural fibrosis. The addition of a contrast computed tomographic scan after epidurography allows for more accurate diagnostic interpretation of epidural space pathology. The use of a standard epidurogram technique allows this procedure to be used in the differential diagnosis of suspected problems in the epidural space.

Pancreatic and biliary calculi: percutaneous treatment with tunable dye laser lithotripsy.

Percutaneous tunable dye laser lithotripsy was used in two patients to successfully fragment a 2-cm left hepatic duct calculus and a 5-mm main pancreatic duct calculus. Tunable dye laser lithotripsy may prove to be a more effective alternative to mechanical lithotripsy.

Recombinant human tissue-type plasminogen activator is an effective agent for thrombolysis of peripheral arteries and bypass grafts: preliminary report.

The efficacy, safety, and effects on hemostasis and coagulation of two doses of human tissue-type plasminogen activator in patients with acute and subacute peripheral arterial occlusion were compared. Seven patients with lower extremity ischemia and one patient with upper extremity ischemia had peripheral arterial thromboses (five arteries, three grafts) confirmed by clinical history, physical examination, and angiography. The duration of occlusion ranged from 31 hours to 30 days (mean 11.9 days). Tissue-type plasminogen activator was infused via a catheter directly into the thrombus at a randomly assigned dose of 0.05 mg/kg/hr (n = 4) or 0.025 mg/kg/hr (n = 4). Thrombolysis was complete in seven patients and partial in one. Duration of infusion ranged from 1 hour to 21 hours (mean 7.4 hours). The low dose required a longer infusion than did the high dose, but they were both successful in achieving thrombolysis. The one patient with partial thrombolysis had abrupt discontinuation of infusion when extravasation through a recently endarterectomized femoral artery developed. Otherwise there were no significant complications from tissue-type plasminogen activator therapy. Secondary procedures to correct underlying arterial disease were performed in five of the seven patients (71%) who had complete thrombolysis. Even at low dosages, infusion of tissue-type plasminogen activator into arteries or bypass graft thrombus produced complete thrombolysis, and no major complications occurred. This allowed more systematic effects to diagnose and treat underlying arterial disease.