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