P011: CHALLENGES IN THORACIC EPIDURAL ANALGESIA: A CASE REPORT OF INTRAPLEURAL CATHETER MISPLACEMENT
Neslida Kodra, DO; Adam Sugarman, MD; Alexis Garcia, MD; Guillermo Garcia, MD; Hala Baaj, MD
Mount Sinai Medical Center
Introduction/Background: Thoracic epidural analgesia (TEA) is the gold standard for perioperative pain management in thoracic surgeries, offering superior pain control, reduced systemic opioid requirements, and preserved respiratory mechanics. However, complications of TEA include rare but published cases of catheter misplacement into the intrapleural space. We present the case of a 79-year-old female undergoing robotic-assisted video-assisted thoracoscopic surgery (VATS) for a left lower lobe lung mass, where intrapleural catheter placement was identified intraoperatively and managed without adverse outcomes.
Methods: A 79-year-old female with scoliosis and BMI of 32 underwent robotic-assisted VATS for pulmonary mass resection. A thoracic epidural catheter was placed preoperatively at the T7-T8 interspace via paramedian approach using a 17-gauge Tuohy needle. Loss of resistance with air was achieved at 6 cm, and the catheter was threaded 7 cm beyond the needle tip and secured. A test dose of 3 mL 1.5% lidocaine with epinephrine was administered to rule out intrathecal or intravascular placement. No complications were noted during or immediately after placement. Standard induction and double-lumen intubation were performed, and the epidural was loaded with 7 mL of 0.25% bupivacaine before incision.
Results: During surgery, the epidural catheter was visualized in the left intrapleural space (Figure 1). There was no evidence of lung injury. The catheter was immediately removed, and surgery proceeded uneventfully. The patient was extubated and transferred to PACU in stable condition, oxygenating well on nasal cannula. Pain was managed effectively with two doses of hydromorphone 0.2 mg IV. A chest tube placed intraoperatively showed no air leak. The patient was discharged on postoperative day three without complications.
Discussion/Conclusion: Reported TEA failure rates in the literature are as high as 30%, primarily due to catheter misplacement or migration, which can lead to failed analgesia or complications like pneumothorax or hemothorax. Intrapleural misplacement is likely under-reported, as most cases are detected intraoperatively in the ipsilateral cavity, with contralateral misplacements often going undiscovered.
Distorted patient anatomy from obesity, spinal stenosis, scoliosis and older age increases risk of misplacement. The paramedian approach, commonly used for thoracic epidural placement due to the downward angulation of thoracic spinous processes, bypasses calcified or distorted midline structures, but diminishes the loss- of- resistance sensation, thereby making it more difficult to confirm entry into the epidural space.
Detecting misplaced catheters preoperatively or intraoperatively is challenging. Traditional methods like aspiration and test dosing have limited utility in identifying pleural placement and imaging modalities such as fluoroscopy and chest X-ray are not routinely used due to time, cost, and radiation exposure. Ultrasound guidance can improve placement accuracy and first- pass success in patients with challenging anatomy.
Although the misplaced catheter in this case was removed promptly, similar cases in the literature suggest that intrapleural catheters can provide adequate analgesia when repositioning is not feasible. Some studies demonstrate satisfactory pain control with higher doses of local anesthetic administered via intrapleural catheters.
In conclusion, this case addresses patient factors and procedural approaches that complicate thoracic epidural placement, as well as considerations for prevention and management of misplaced catheters.