1 Department of Anaesthesiology, Sahel General Hospital, Beirut, Lebanon. 2 Department of Anaesthesiology, Centre Clinical, 2 Chemin de Frégeneuil, 16800 Soyaux, France. 3 Department of Anaesthesiology and Critical Care, Bicetre Hospital, 78 rue du General Leclerc, 94275 Le Kremlin Bicetre, France
*Corresponding author: Department of Anaesthesiology, Sahel General Hospital, Lebanese University, Airport Avenue, PO Box 99/25 Ghobeiry, Beirut, Lebanon. E-mail: doczeidan@hotmail.com
Accepted for publication: September 1, 2003
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Abstract |
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Br J Anaesth 2004: 92: 1468
Keywords: analgesic techniques, epidural; complications, nerve irritation; surgery, paediatric
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Introduction |
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We report a case of transient postoperative neurological symptoms in a 6-yr-old child who was receiving epidural analgesia after renal surgery.
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Case report |
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On the morning of the first postoperative day, the child was anxious and restless, and suffered from severe pain in the right groin, radiating to the anterior surface of the thigh. Neurological examination revealed severe pain in the right lower quadrant of the abdomen with sensory loss on the anterior surface of the right thigh, suggesting a lesion in the L2 dermatome. No motor deficit was noticed and all deep tendon reflexes were present. The epidural catheter, the drug dosage and the infusion rate were checked. The local anaesthetic infusion was stopped and the epidural catheter was removed.
A parenteral opioid-based regime and bed rest were sufficient to relieve the pain and a complete neuro logical recovery was seen within 24 h, without any further complaint.
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Discussion |
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Mechanical irritation of the nerve root by the epidural catheter is the most likely explanation of the postoperative pain in this child, especially as the symptoms disappeared completely after removal of the epidural catheter. One contributing factor could have been the length of the epidural catheter introduced into the epidural space (5 cm), which might have been too long in this 21 kg child. One study in obstetric patients has shown that 5 cm is the optimal distance that the epidural catheter should be threaded into the epidural space and that a greater distance may lead to asymmetrical analgesia.12 In another obstetric study, epidural catheters threaded for only 2 cm were associated with a greater incidence of dislodgement, especially in prolonged labour.13 This study suggests that, when a catheter is sited for postoperative pain relief over several hours, a relatively long part of the catheter should be threaded into the epidural space. Unfortunately, however, there are no studies assessing the optimal length of epidural catheter to be introduced into the epidural space in adults or children for postoperative analgesia. Dalens14 has recommended insertion of the epidural catheter for 2 cm in children. We would concur that insertion of an epidural catheter for more than 2 cm in children should be avoided as this might lead to mechanical nerve root irritation. In this child a painful complaint highlighted the problem. But the incidence of painless symptoms or other minor neural events could be underestimated. They cannot be easily diagnosed unless regular postoperative follow-up is undertaken as part of a quality assurance programme. Moreover, pain or paraesthesia may occur during needle placement or insertion of the epidural catheter, highlighting the risk of potential problems, but these symptoms will be hidden by general anaesthesia in paediatric practice.
Thus we believe that the increasing use of regional anaesthesia in paediatric surgery should encourage anaesthetists to seek silent neurological injuries in the postoperative period.
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References |
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