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An unusual case of haemorrhage
Correspondence
An unusual case of haemorrhage
We would like to report a case of significant and prolonged bleeding from the site of a Tuohy needle skin puncture made during lumbar epidural insertion for labour analgesia. A fit 29-year-old G2P1 woman presented in spontaneous labour at 38 weeks of gestation. She had previously undergone caesarean section for a breech presentation. Her current pregnancy was complicated by cholestasis. She requested epidural analgesia at 3 cm cervical dilation. The procedure was performed with the woman in the sitting position, using a full aseptic technique, 1% lidocaine skin infiltration and a 16gauge Tuohy needle. The first attempt was unsuccessful as it was felt that the Tuohy needle was not in the midline as it had not been held firmly in the ligaments and was abandoned after advancement of the needle to a depth of only 3 cm. On the second attempt, using a different puncture site, the catheter was successfully placed at L3-4 using loss-of-resistance to saline; the epidural space was identified at 6 cm and the catheter secured at 9.5 cm to skin. A test dose of 0.1% bupivacaine 10 mL with fentanyl 2 lg/mL was given followed 10 min later by a second 10 mL dose of the same solution with good effect. The epidural dressing was noted to be bloody before the first midwife top-up approximately 2 h later. However, a decision was made for observation and continuation with the epidural catheter. The site was reviewed several times throughout labour with persistent bleeding and large clots found at each dressing change. There was an approximate blood loss of 50–100 mL/h amounting to an estimated loss of 600–800 mL over a 10-h period. On close inspection there was found to be pulsatile spurting from the site of the first Tuohy needle insertion. The bleeding did not abate despite several pressure dressings and 45 min of direct digital pressure. Although initially providing good analgesia, the persistent bleeding caused the catheter to become dislodged and so it was removed. There was no bleeding from the site of the successful epidural catheter placement. The patient remained haemodynamically stable throughout with mean arterial pressures of 90–100 mmHg and a heart rate of 90–100 beats/min. The results of bloods taken on admission were: haemoglobin 9.6 g/dL, platelet count 197 · 109/L, prothrombin time 9.8 s, activated partial thromboplastin time 24.6 s. Urea and electrolytes and urate levels were all normal. The baby was eventually delivered by emergency caesarean section for failure to progress. General anaesthesia was chosen due to the continued bleeding. Surgery passed without incident and estimated blood loss was 700 mL. Before emergence the patient was rolled for skin cleaning and the epidural insertion site was in-
263 spected and was found not to be bleeding. The patient was reviewed the following day on the ward and the epidural puncture sites remained dry and free from bruising. There was no neurological impairment. On a review of the literature only three similar case reports could be found,1–3 all describing similar continuous pulsatile bleeding from epidural insertion sites during labour. In these cases, however, the blood loss described was significantly less and all cases required active intervention including, a purse-string suture,1 and subcutaneous infiltration of adrenaline post delivery.2,3 We could find no reports of this complication occurring outside of the labour ward. When siting an epidural catheter, the Tuohy needle may damage various vascular structures. The skin and adipose tissue are supplied by a low-pressure arteriolar and capillary network; damage to these small vessels causes minor self-limiting bleeding often seen at epidural insertion sites. The incidence of this common phenomenon can be reduced by the use of adrenaline containing lidocaine solutions rather than plain lidocaine for skin infiltration.4 The most likely sites of vascular injury to produce such excessive bleeding are either the venous or arterial plexi of the epidural space. The epidural space is drained via the valveless, vertebral venous plexus of Bateson which is formed from four trunks, two adjacent to the posterior longitudinal ligament and two in front of the vertebral arches, which communicate freely at each level. The plexus also receives the basivertebral veins, and communicating branches from the vertebral, ascending and deep cervical, intercostals, lumbar, ilio-lumbar and lateral sacral veins. It is a predominantly anterior spinal canal structure with the posterior portion being variable in size particularly at the lumbar level. Its valveless nature allows a link to be formed from the cerebral veins above to the pelvic veins below and thus increased intra-thoracic or intra-abdominal pressure, as seen in pregnancy and especially labour may lead to shunting of blood and vascular engorgement. Epidural arteries are relatively insignificant and lie mainly laterally in the space. They form an anterior and posterior arcade at each level. It is possible that bleeding was the result of damage to a small superficial artery. A subcutaneous vascular network made up of terminal branches of a number of perforating arteries exists in the lumbar region. The course of these small unnamed arteries that supply local tissues is not predictable and they may easily lie in the path of a Tuohy needle. A spinal vascular malformation was also considered. These are rare with the vast majority being asymptomatic. The group consists of spinal arteriovenous malformations, dural arteriovenous fistulas, spinal haemangioma, cavernous angiomas, and aneurysms. They may be diagnosed on magnetic resonance imaging (MRI) although they can be difficult to detect and may require spinal angiography. Given the rarity of these condi-
264
Correspondence
tions and the other clinical possibilities, we felt that MRI was not indicated in this case; this was confirmed after discussion with our neurosurgical colleagues. Although pulsatile bleeding is usually associated with arterial puncture, in the clinical situation of pregnancy and labour in particular, raised intra-abdominal pressure can cause increased venous pressure within the valveless venous plexus of Bateson potentially producing significant haemorrhage. Anaesthetists should be reminded of the potential for damage to these vascular structures, especially in the obstetric patient. Thankfully, it would seem that cases such as ours are rare. C. Taylor, S. Chitre Department of Anaesthetics Whipps Cross University Hospital, London, UK E-mail address: [email protected]
References 1. Ananthanarayan C, Haley S. Prolonged bleeding from epidural insertion site. Can J Anaesth 1988;34:322. 2. Cohen S, Amar D. Prolonged bleeding from epidural catheterisation. Can J Anaesth 1989;36:482–3.
3. Cohen S, Kis G, Burley E. Prolonged bleeding from epidural catheterisation reconsidered. Anaesthesia 1999;54:719. 4. Carvalho B, Fuller A, Brummel C, Cohen SE. Local infiltration of epinephrine-containing lidocaine with bicarbonate reduces superficial bleeding and pain during labour epidural catheter insertion: a randomized trial. Int J Obstet Anesth 2007;16:116–21.
0959-289X/$ - see front matter
c 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ijoa.2013.02.002
A novel airway checklist for obstetric general anaesthesia Management of the obstetric patient’s airway is a significant source of anxiety to all anaesthetists as a result of the combined risks of possible difficult intubation, increased susceptibility to hypoxaemia and potential for pulmonary aspiration of gastric contents. A recent innovation in medicine has been the development of clinical checklists for a variety of situations. The main aim is to reduce human error through good preparation and rapid identification of potential difficulties. Using check-
Fig. 1 Airway checklist for obstetric general anaesthesia. EtO2: end-tidal oxygen fraction; FRC: functional residual capacity; ETT: endotracheal tube; LMA: laryngeal mask airway; RSI: rapid-sequence induction.
An unusual case of haemorrhage
We would like to report a case of significant and prolonged bleeding from the site of a Tuohy needle skin puncture made during lumbar epidural insertion for labour analgesia. A fit 29-year-old G2P1 woman presented in spontaneous labour at 38 weeks of gestation. She had previously undergone caesarean section for a breech presentation. Her current pregnancy was complicated by cholestasis. She requested epidural analgesia at 3 cm cervical dilation. The procedure was performed with the woman in the sitting position, using a full aseptic technique, 1% lidocaine skin infiltration and a 16gauge Tuohy needle. The first attempt was unsuccessful as it was felt that the Tuohy needle was not in the midline as it had not been held firmly in the ligaments and was abandoned after advancement of the needle to a depth of only 3 cm. On the second attempt, using a different puncture site, the catheter was successfully placed at L3-4 using loss-of-resistance to saline; the epidural space was identified at 6 cm and the catheter secured at 9.5 cm to skin. A test dose of 0.1% bupivacaine 10 mL with fentanyl 2 lg/mL was given followed 10 min later by a second 10 mL dose of the same solution with good effect. The epidural dressing was noted to be bloody before the first midwife top-up approximately 2 h later. However, a decision was made for observation and continuation with the epidural catheter. The site was reviewed several times throughout labour with persistent bleeding and large clots found at each dressing change. There was an approximate blood loss of 50–100 mL/h amounting to an estimated loss of 600–800 mL over a 10-h period. On close inspection there was found to be pulsatile spurting from the site of the first Tuohy needle insertion. The bleeding did not abate despite several pressure dressings and 45 min of direct digital pressure. Although initially providing good analgesia, the persistent bleeding caused the catheter to become dislodged and so it was removed. There was no bleeding from the site of the successful epidural catheter placement. The patient remained haemodynamically stable throughout with mean arterial pressures of 90–100 mmHg and a heart rate of 90–100 beats/min. The results of bloods taken on admission were: haemoglobin 9.6 g/dL, platelet count 197 · 109/L, prothrombin time 9.8 s, activated partial thromboplastin time 24.6 s. Urea and electrolytes and urate levels were all normal. The baby was eventually delivered by emergency caesarean section for failure to progress. General anaesthesia was chosen due to the continued bleeding. Surgery passed without incident and estimated blood loss was 700 mL. Before emergence the patient was rolled for skin cleaning and the epidural insertion site was in-
263 spected and was found not to be bleeding. The patient was reviewed the following day on the ward and the epidural puncture sites remained dry and free from bruising. There was no neurological impairment. On a review of the literature only three similar case reports could be found,1–3 all describing similar continuous pulsatile bleeding from epidural insertion sites during labour. In these cases, however, the blood loss described was significantly less and all cases required active intervention including, a purse-string suture,1 and subcutaneous infiltration of adrenaline post delivery.2,3 We could find no reports of this complication occurring outside of the labour ward. When siting an epidural catheter, the Tuohy needle may damage various vascular structures. The skin and adipose tissue are supplied by a low-pressure arteriolar and capillary network; damage to these small vessels causes minor self-limiting bleeding often seen at epidural insertion sites. The incidence of this common phenomenon can be reduced by the use of adrenaline containing lidocaine solutions rather than plain lidocaine for skin infiltration.4 The most likely sites of vascular injury to produce such excessive bleeding are either the venous or arterial plexi of the epidural space. The epidural space is drained via the valveless, vertebral venous plexus of Bateson which is formed from four trunks, two adjacent to the posterior longitudinal ligament and two in front of the vertebral arches, which communicate freely at each level. The plexus also receives the basivertebral veins, and communicating branches from the vertebral, ascending and deep cervical, intercostals, lumbar, ilio-lumbar and lateral sacral veins. It is a predominantly anterior spinal canal structure with the posterior portion being variable in size particularly at the lumbar level. Its valveless nature allows a link to be formed from the cerebral veins above to the pelvic veins below and thus increased intra-thoracic or intra-abdominal pressure, as seen in pregnancy and especially labour may lead to shunting of blood and vascular engorgement. Epidural arteries are relatively insignificant and lie mainly laterally in the space. They form an anterior and posterior arcade at each level. It is possible that bleeding was the result of damage to a small superficial artery. A subcutaneous vascular network made up of terminal branches of a number of perforating arteries exists in the lumbar region. The course of these small unnamed arteries that supply local tissues is not predictable and they may easily lie in the path of a Tuohy needle. A spinal vascular malformation was also considered. These are rare with the vast majority being asymptomatic. The group consists of spinal arteriovenous malformations, dural arteriovenous fistulas, spinal haemangioma, cavernous angiomas, and aneurysms. They may be diagnosed on magnetic resonance imaging (MRI) although they can be difficult to detect and may require spinal angiography. Given the rarity of these condi-
264
Correspondence
tions and the other clinical possibilities, we felt that MRI was not indicated in this case; this was confirmed after discussion with our neurosurgical colleagues. Although pulsatile bleeding is usually associated with arterial puncture, in the clinical situation of pregnancy and labour in particular, raised intra-abdominal pressure can cause increased venous pressure within the valveless venous plexus of Bateson potentially producing significant haemorrhage. Anaesthetists should be reminded of the potential for damage to these vascular structures, especially in the obstetric patient. Thankfully, it would seem that cases such as ours are rare. C. Taylor, S. Chitre Department of Anaesthetics Whipps Cross University Hospital, London, UK E-mail address: [email protected]
References 1. Ananthanarayan C, Haley S. Prolonged bleeding from epidural insertion site. Can J Anaesth 1988;34:322. 2. Cohen S, Amar D. Prolonged bleeding from epidural catheterisation. Can J Anaesth 1989;36:482–3.
3. Cohen S, Kis G, Burley E. Prolonged bleeding from epidural catheterisation reconsidered. Anaesthesia 1999;54:719. 4. Carvalho B, Fuller A, Brummel C, Cohen SE. Local infiltration of epinephrine-containing lidocaine with bicarbonate reduces superficial bleeding and pain during labour epidural catheter insertion: a randomized trial. Int J Obstet Anesth 2007;16:116–21.
0959-289X/$ - see front matter
c 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ijoa.2013.02.002
A novel airway checklist for obstetric general anaesthesia Management of the obstetric patient’s airway is a significant source of anxiety to all anaesthetists as a result of the combined risks of possible difficult intubation, increased susceptibility to hypoxaemia and potential for pulmonary aspiration of gastric contents. A recent innovation in medicine has been the development of clinical checklists for a variety of situations. The main aim is to reduce human error through good preparation and rapid identification of potential difficulties. Using check-
Fig. 1 Airway checklist for obstetric general anaesthesia. EtO2: end-tidal oxygen fraction; FRC: functional residual capacity; ETT: endotracheal tube; LMA: laryngeal mask airway; RSI: rapid-sequence induction.