Cousin&bridenbaugh

Continuous Spinal Anesthesia

To produce continuous spinal anesthesia, a catheter may be inserted into the subarachnoid space and small, repeated doses of local anesthetic given. The benefits of this technique are that it could prevent the hypotension due to excessive sympathetic block caused by the large spread of anesthesia, and it would allow adequate anesthesia to be continued for as long as needed. Because the relatively large needle needed to insert a regular catheter causes the risk of headache, small microcatheters (32-gauge) that could be inserted through 25-gauge needles were introduced early in the 1990s (200). Unfortunately, the use of these microcatheters, together with overdoses of hyperbaric local anesthetics, caused several permanent cauda equina syndromes (23) and U.S. Food and Drug Administration (FDA) prohibited their use (244,245). Continuous spinal anesthesia is, however, still quite commonly used. Either epidural catheters in the subarachnoid space, inserted through 18- to 20-gauge Tuohy needles, special catheters (CoSpan, Kendall; 28-gauge catheter through a 22-gauge needle), or a specially designed catheter-over-the-needle design (Spinocath; BBraun) are used. In the latter, an 18-gauge Crawford-type epidural needle is first inserted in the epidural space and then a special 22-gauge catheter over a 27-gauge needle is advanced through the Crawford needle and the dura is punctured. After ascertaining CSF flow through the catheter, it is kept immobile while the needle is withdrawn (201). For continuous spinal anesthesia, the catheter should point cranially, and this is best achieved by using directional needles. If the needle has a Quincke-type tip, the catheter is easily directed caudally or curled (202). With a caudally directed catheter, the spread of anesthesia is limited and an increase in dose causes the local anesthetic to accumulate in a small area, thus increasing the risk of neurotoxicity. The catheter should be introduced only 2 to 3 cm, otherwise the tip may be too cranial or turn to the side and anesthesia may become segmental. Plain (close to isobaric) solutions are preferred (203). The spread is easier to predict with plain solutions, and all the known cauda equina cases happened after the use of hyperbaric solutions. So far, the most experience is with bupivacaine (12,204). Levobupivacaine or ropivacaine may be as good and safe alternatives (205). Even though it would be logical to use fast and short-acting lidocaine, it is not recommended because of the potential for neurotoxicity. If the anesthesia has not spread after a reasonable dose (1015 mg of bupivacaine) and time (20 minutes), one must assume that the catheter is pointing caudally and extreme caution should accompany any extra doses. If onset of spinal block occurs, but the spread is not adequate, a small dose of local anesthetic with different baricity (bupivacaine and sterile water; hypobaric) is worth a try. If the spread is still not adequate, the technique must be abandoned (204). This technique is used mostly in elderly and hemodynamically unstable (the small dose lessens the risk of hypotension) and long operations (to continue the anesthesia for as long as needed). These patients are not in the highest-risk groups of PDPPH (206). It is also assumed that, because the catheter remains through the dura, it causes an inflammatory reaction that promotes the closure of the hole and diminishes the leak of CSF. The risk of headache is higher in younger, active populations. In a study (207) of 18- to 30-year-old healthy volunteers, in which through-catheter or catheter-over-needle techniques were used, 78% experienced PDPPH. The catheters were used for collecting of CSF samples (17 0.5 mL) for 4 hours. This situation is different from that in the surgical setting, and the clinical relevance may be questionable. Continuous spinal anesthesia has also been used also for treatment of postoperative pain Complications of regional anesthesia

Continuous Spinal Anesthesia

Spinal catheters can be used for repeating dosing or continuous infusion of drugs into the subarachnoid space. Excessive block can be avoided with careful titration of the drugs into catheter. With more restricted block, there is smaller risk for cardiovascular complications such as hypotension and bradycardia. If the duration of surgery is long, additional doses of local anesthetics can be injected. The use of catheters can be extended also for postoperative analgesia. In the beginning of the 1990s, 14 cases of cauda equina syndrome were reported in association with the use of small-gauge spinal catheters. This led to the withdrawal of the microcatheters from the market in the United States and Canada. The mechanism

of these unhappy events was probably attributable to direct toxic effect of local anesthetic. Maldistribution or potential pooling of local administered through the catheters near the roots of cauda equina is the most likely explanation. Therefore, hyperbaric local anesthetics should be avoided with microcatheters. Injection of hyperbaric solution through a single-hole microcatheter may lead to neurotoxic concentrations of local anesthetic in CSF. The risk seems to increase when the catheter is directed caudad and glucose-containing solutions are injected. Unfortunately, it is impossible to predict the direction of a subarachnoid catheter despite attempts to direct it cranially at least with sharp-beveled needles.89 More accurate positioning maybe achieved by using directional puncture needles such as Sprotte or Tuohy needles. The catheter should not be advanced more than 2 3 cm into subarachnoid space. Small-gauge spinal catheter systems with different techniques of dural perforation have been developed to reduce the risk of PDPH in continuous spinal anesthesia. Despite different catheter designs, the incidence of PDPH seems to be high with the risk patients. An incidence of 78% has been reported with the over-the-needle catheter technique.90 Spinal cutaneous fi stula is a rare but harmful complication of continuous spinal anesthesia. In one reported case, the fi stula followed a 5-hour catheterization with an 18-gauge epidural nylon catheter. The fi stula was closed with a single stitch, deep, at the puncture site.91 There are many technical problems associated with placement of small-diameter spinal catheters. Coiling and kinking of the catheters, catheter breakage, and failure to aspirate have been problems associated with these catheters. Over-the-needle devices have been associated with high failure rates.92 Traumatic catheter placement can in worst case lead to spinal hematoma that fortunately is a rare but a potentially catastrophic complication of spinal catheterization. Spinal catheters should be properly marked and the personnel that manage the patients should be aware of the proper use of spinal catheters and the possible complications associated with them. Injecting the wrong solution into subarachnoid space can cause disastrous complications for the patient. Strict aseptic routine should be used during the insertion and use of spinal catheters. There are no prospective studies about the incidence of infective complications associated with the use of these catheters. Occasional case reports have been published about aseptic meningitis during continuous spinal analgesia. The preservatives have been suspected to be the cause of meningitis.93 There are no data either about the safe time period that the spinal catheter can be used. In most studies, the spinal catheter had remained in situ for 1 or 2 postoperative days. Catheter breakage can also occur during catheter withdrawal. During withdrawal of the catheter, the patient should be positioned preferably in the same position as during the insertion of the catheter. Excessive force should be avoided. Catheter removal is not acceptable during therapeutic levels of anticoagulation. The catheter must be checked after removal and if broken pieces are retained in the patient, they should be informed about the incident. It is recommended to leave possible broken pieces in situ if they do not cause problems such as CSF fi stula.

Subarachnoid Catheters
Technical Problems and Complications
Continuous spinal anesthesia was repopularized in the 1980s, with the development of microcatheters (29 and 32 gauge).108 From the very beginning, and still today, the problems encountered with microcatheters have centered around technical diffi culties

in passing the thin catheter through a small needle. Coiling and kinking of the catheters, catheter breakage, and failure to aspirate were noted already in the initial trials. Built-in and removable stylets have been applied for the prevention of kinking and breakage.109,110 The considerable failure rate for inserting the thin 32-gauge microcatheter experienced in our own department, 25%,111,112 have been similar to those in other studies.113 Literature on continuous spinal anesthesia using large-caliber equipment (epidural catheters) rarely makes any mention of unsuccessful lumbar puncture or catheter insertion. However, in three studies on continuous spinal anesthesia with 20-gauge catheters, unsuccessful catheterization occurred in 4.3%,114 3.2%,79 and 1% of cases.115 A practical problem encountered with the 32-gauge polyurethane catheter with removable stylet, and occasionally with the 28-gauge nylon catheter, has been stretching during attempts to remove the catheter.112,116 Catheter breakage during removal may occur.108,112,116 If the break point is outside the skin or immediately below the surface, the distal part of the catheter may be retrieved after fi rst repositioning

Hemorrhage
The subarachnoid puncture with a needle and the insertion of a plastic catheter can cause damage to blood vessels and the nervous tissue. No serious bleeding complications (e.g., spinal hematoma) from continuous intrathecal catheters have been reported in the literature. However, a considerable number of erythrocytes were observed in the CSF of several patients who were given continuous spinal (intrathecal) anesthesia via a 22-gauge epidural catheter.117 The erythrocyte count in this small patient population seemed to be independent of whether or not the patients had received lowmolecularweight heparin for thromboprophylaxis preoperatively (hip or knee arthroplasties), or intravenous heparin intraoperatively (vascular surgery). The amounts of erythrocytes (maximally 20 109/L), which result in macroscopically blood-tinged CSF, can easily be handled by arachnoid villi and, therefore, from a neuropathologic point of view the hemorrhage can be considered insignifi cant. No neurologic complications ensued in that particular patient population.117 The fi nding of no signifi cant complications attributable to the presence of erythrocytes in the CSF during continuous spinal anesthesia is substantiated by the results of a prospective study in which minor hemorrhage was observed in the puncture needle of the spinal catheter in 18 of 46 cases.118 This particular study also indicates that preoperative antiplatelet nonsteroidal antiinfl ammatory drug therapy does not increase the risk of spinal hematoma associated with spinal or epidural anesthesia.

Infectious Complications
Serious infectious complications associated with continuous spinal anesthesia have not been reported. In a study of 66 surgical patients in our own department, in which CSF was sampled at intervals of 24 hours, an excess of leukocytes was observed in the 24-hour sample of one patient.117 The bacterial culture showed S. epidermidis. The patient was symptom free with no leukocytosis in the blood and was treated with intravenous antibiotics. The fact remains that the excess of leukocytes in the CSF would not have been detected in the symptom-free phase had repeat CSF sampling not been performed as scheduled. Standl and coworkers119 reported one contaminated catheter tip (S. epidermidis) in 100 spinal catheters used for postoperative analgesia and removed after 24 hours. Both of these cases probably represent contamination from normal skin bacterial fl ora; S. epidermidis, for example, is readily adherent to plastic material indwelling in

the body. The presence of bupivacaine (3.75 5 mg/mL) inside the catheter may prevent microorganism growth to some extent.76,77 Furthermore, a bacterial fi lter (diameter 0.22 g) must always be used on the catheters.

Headache and Neurologic Complications

The primary factor that has limited the use of continuous spinal anesthesia is the belief that the relatively large size of the puncture needle, as well as the use of epidural catheters as intrathecal catheters, requiring insertion through still larger needles, will result in a high incidence of PDPH. This contention is controversial, however (Table 15-1). In the particular study that clearly renewed interest in the use of the continuous spinal technique, there was only one case of PDPH among 117 surgical patients who received a 20-gauge intrathecal catheter through an 18-gauge needle.79 The reason for this low incidence of PDPH was postulated to be an infl ammatory reaction in the dura mater and the arachnoid surrounding the puncture site, which, as a result of edema and fi brinous exudate, would seal the hole in the dura after catheter removal. With the use of the 32-gauge microcatheter, the incidence of PDPH in the fi rst report was 4%.108 In elderly patients, the incidence of PDPH associated with the 32-gauge spinal catheter has been zero.111,112 Microcatheters for continuous spinal anesthesia have also been used in children.125 Extravasation was noticed when the 28-gauge catheter was left in situ for 24 hours in some of the pediatric patients. Catheters smaller than 27 gauge are no longer approved by the regulatory agencies of various countries (others have released warnings), which seems to be the logical reason why continuous spinal techniques are rarely used in children nowadays. The reason for withdrawal of microcatheters (smaller than 27 gauge) for spinal anesthesia from the North American market was the report of at least 14 cases of cauda equina syndrome after continuous spinal anesthesia to the Food and Drug Administration (FDA) in the beginning of 1990s. An offi cial Safety Alert was issued by the FDA in May 1992. However, in most European countries, 28-gauge, but not 32-gauge, catheters are in routine use today. The occurrence of the above-mentioned cauda equina syndromes is not, obviously, caused by the catheter per se, but indirectly so that the thin catheter easily turns into the caudal direction126 and an injected hyperbaric local anesthetic solution becomes pooled in the vicinity of the roots of the cauda equina, producing direct local anesthetic tissue toxicity.127,128 Therefore, when small-bore catheters are used for continuous spinal anesthesia, the catheters should not be advanced more than 3 4 cm into the subarachnoid space, and hyperbaric local anesthetic solution should be considered contraindicated. Better and predictable positioning of the tip of the intrathecal catheter can be achieved by using directional puncture needles (Tuohy, Sprotte).129 The problem of predicting the positioning of the catheter tip in the intrathecal space, and in order to eliminate leakage of CSF through the puncture hole in the dura, around the inserted catheter, the spinal catheter (22 or 24 gauge) may be introduced over the spinal needle (27 or 29 gauge).129 Despite the relatively ingenious technical approach, this catheter set has turned out to be technically rather diffi cult to handle.