Electrical stimulation test for epidural catheter placement after receiving intrathecal local anesthetic during a combin
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CORRESPONDENCE
Electrical stimulation test for epidural catheter placement after receiving intrathecal local anesthetic during a combined spinal-epidural technique for Cesarean delivery: confirmation of the spinal nerve root as epidural site of action Malcolm Stewart, MD . Brendan Carvalho, MD . Ban C. H. Tsui, MD, MSc
Received: 5 October 2019 / Revised: 20 October 2019 / Accepted: 21 October 2019 Ó Canadian Anesthesiologists’ Society 2019
To the Editor, The epidural stimulation test (EST) has been shown to have a higher sensitivity than the local anesthetic test dose to predict adequate epidural analgesia following abdominal surgery.1,2 In obstetrical patients, this test can confirm the proper epidural catheter placement in labouring women receiving low-dose combined spinal epidural (CSE).3 Confirmation of epidural catheter placement after a full surgical spinal dose CSE for Cesarean delivery is important as epidural failure (1.7%) is a known complication of the CSE procedure.4 We share our experience of applying an EST via the epidural catheter following full surgical spinal dose of CSE for Cesarean delivery. A 43-yr-old gravida 5 para 2 woman at 39 weeks and two days gestation (who provided written consent for this report) presented for elective Cesarean delivery. Past obstetrical history was significant for two prior Cesarean deliveries with the previous operative report noting significant bladder adhesions to the anterior abdominal wall. Given this history and the concern for a potential prolonged surgical time, the decision was made to place a CSE. In the sitting position, a 17G, 9-cm Tuohy needle (Perifix continuous epidural tray, BBraun, Bethlehem, PA, USA) was inserted and the epidural space was identified at 5.5 cm depth using a loss of resistance to saline technique. A 26G, 124-mm spinal needle (GM 26124-I, Gertie Marx, Huntsville, UT, USA) was then inserted through the Tuohy, and after confirming return of cerebrospinal fluid, 1.4 mL 0.75% bupivacaine, 15 lg fentanyl, and 150 lg M. Stewart, MD B. Carvalho, MD B. C. H. Tsui, MD, MSc (&) Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Palo Alto, CA, USA e-mail: [email protected]
morphine was injected intrathecally. Following this, a 19G epidural catheter was inserted through the Tuohy needle. The epidural catheter was then capped with an Arrow Snaplock adapter from the stimulation catheter kit (Arrow Stimucath cPNB catheter kit, Teleflex, Morrisville, NC, USA) and the epidural catheter pulled back to 10 cm and secured to the skin with a bio-occlusive dressing. With the patient positioned supine with left-uterinedisplacement, normal saline 1 mL was injected into the epidural catheter and a nerve stimulator (Digistim 2 Plus, Neuro Technology, Houston, TX, USA) was attached to the metal flange on the Snaplock adapter. We were then able to elicit a motor response at 7.0 mA (0.1 msec pulse width) as shown by bilateral (left [ right) quadriceps twitching, without patient discomfort. At the time the EST was perfo
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