Med Journal Sept 2020 Final | Page 10

Cover Case Study Story by Anita Akbar Ali, MD; 1 Nazish Hashmi, MD; 2 Mark A. Stevens, MD 3 1 Assistant Professor of Anesthesiology, UAMS 2 Assistant Professor of Anesthesiology, Duke University 3 Anesthesiologist, Baptist Health Medical Center Little Rock Doctor, My Epidural Site is Leaking! A Diagnostic Dilemma in An Anxious Post-Partum Patient Abstract Neuraxial anesthesia blocks are safe and have been in use since the 1970s. Despite their wide-spread use, some stigma still follows regarding the potential harm. We present the case of a 27-yearold female who developed a rare presentation of edema fluid draining out from the epidural site. The report is significant, as this rare clinical presentation is scarcely reported. Also, this unusual and terrifying experience may have changed the perspective of the patient for her future labor analgesics options. This report further highlights the responsibility of physicians to counsel patients and provide them adequate support in case of unexpected outcomes. It is the responsibility of a physician to address concerns and counsel patients and their families in case of unusual clinical outcome. Introduction Obstetrics anesthesia has evolved from a painful experience of childbirth to a pain-free, joyous moment of one’s life. It all changed with the placement of the first labor epidural almost 50 years ago. Over the years, the technique and medications have significantly improved the way epidurals are utilized for labor and delivery, making them a much safer and more reliable anesthetic option. Still, the general population continues to have varying opinions regarding risks related to the safety of epidurals. Individual experiences; experiences of friends, family, and co-workers; and information available online and in non-medical literature influence the decision making of patients. Our patient was a young primigravida who was apprehensive about getting an epidural and later decided to have it placed. She ended up having an unusual clinical presentation post-partum that made the patient and her family anxious and led her to doubt her own decision. Timely and effective resolution of complications can play a significant role in patients’ perceptions regarding treatment options. Even though it was a relatively harmless complication, this could have led her to perceive neuraxial blocks as more harmful than beneficial. Also, sharing of this incorrect information could have affected multiple other people in their decision-making process for placement of neuraxial anesthetic blocks. Case Presentation Our patient was a healthy 27-year-old primigravida female who presented to the labor and delivery unit for a scheduled induction. She had twin intrauterine gestations with no prenatal complications. Spontaneous vaginal delivery was expected due to vertex presentation of both twins. Patient was anxious getting an epidural catheter, as one of her friends had developed chronic back pain postpartum. In her opinion, the back pain resulted from the difficult placement of epidural catheter. After detailed discussion regarding risks and benefits, she decided to have an epidural catheter for labor analgesia. After application of standard American Society of Anesthesiologists (ASA) monitors, an epidural catheter was placed without any immediate complications. Fetal monitoring was continued during the placement using Cardiotocography (CTG). Patient and fetuses tolerated the procedure well and remained hemodynamically stable. A bolus of 0.12.5% plain Bupivacaine was administered via epidural catheter followed by epidural infusion of eight milliliters (mls) per hour of 0.125% Bupivacaine and Fentanyl (at the concentration of 5mcg/ml). Adequate labor analgesia was achieved within 20 minutes of epidural catheter placement. The twins were delivered without any major complications. Per plan, epidural catheter was left in place for postoperative pain control, with the expected discontinuation after 24 hours. On first post-operative day, patient was evaluated and epidural catheter was discontinued. The patient tolerated the procedure well and remained hemodynamically stable during and after the procedure. Approximately after 16 hours, the on-call resident was called regarding a copious amount of fluid leaking from the epidural puncture site. According to the patient, fluid leakage started one to two hours after the catheter was pulled out and increased slowly over time. The leakage was significant enough to soil her bed and require four-to-five sheet changes per hour. The drainage was continuous, making everyone question the probability of epidural catheter inadvertently puncturing the dura leading to cerebrospinal fluid (CSF) leak. Of note, patient was asymptomatic and did not demonstrate any signs of post-dural-puncture headache. On assessment, patient was hemodynamically stable with no neurological deficits. No signs of inflammation or infection were present at the puncture site. Patient had bilateral lower extremity edema, but it was consistent with preoperative physical findings. The rest of the physical exam was unremarkable. The patient was reassured, and sterile dressing was applied around the puncture site. Within a few minutes, 4-5mls of fluid accumulated within the dressing, creating a fluid-filled pocket (Figure 1). A sample of fluid was collected under sterile technique and was sent for Biochemical analysis. Fluid leak resolved slowly on post-operative day two. The leak stopped completely on post-operative day 58 • The Journal of the Arkansas Medical Society www.ArkMed.org