Anesthesia Patient Safety Foundation March 2018
To the Editor:
Since the Second World War, flip-flops have become an increasingly popular footwear in the United States. Nevertheless, most would agree that their wear is not appropriate in every situation and opinion might differ on what is unacceptable, acceptable, or even desired. Flips-flops at the communal pool seem appropriate, but flip-flops at a wedding may not be. What if it was a beach wedding? What about on an ascent to Machu Picchu?
What is a reasonable idea in one place might be a bad choice in different circumstances. Decisions, therefore, need to be made in the context of the surroundings.
Recently, one of our residents placed an intraspinal catheter after an inadvertent dural puncture in a laboring patient. Although this is not routinely done at our institution and the resident had no experience with this type of catheter, he defended his decision to leave the catheter in situ with numerous articles stating the safety and potential benefits of spinal catheters.1,2 Our case highlights the need to explain and discuss with residents if and under what circumstances results from the current literature can be safely translated into daily practice.
Our resident failed to recognize that unfamiliarity with a spinal catheter could lead to devastating consequences for the mother as well as for the baby if the catheter was to be mistaken to be in the epidural space. For example, opioid dosages for epidural versus intrathecal administration are substantially different and could lead to unexpected respiratory depression if the typical epidural dose was given intrathecally. Consequences include hypoxemia leading to cardiac arrest, irreversible brain damage, and even death. The updated guidelines of the American Society of Anesthesiologists from 2016 regarding neuraxial opioid administration discuss appropriate considerations to prevent, detect, and manage respiratory compromise.3 For example, in order to reduce the risk of respiratory depression, they advise using the lowest effective dose of an intrathecal opioid. An epidural dose given intrathecally would typically be far higher than needed or desired. The practice guidelines for obstetric anesthesia by the American Society of Anesthesiologists do not contain specific recommendations for the use of intraspinal catheters.4 However, it is clear that an accidental epidural dose given intrathecally could result in serious patient harm.5
Our concern was that a clinician would administer a presumed epidural bolus during an attempt to increase the anesthetic level or with the aim to convert to a surgical block for cesarean section. This could lead to a high spinal and consequently severe complications. Therefore, as a department, we agreed with the attending, who upon notification of the spinal catheter, ordered the removal of the intraspinal catheter and subsequent replacement with an epidural catheter. Currently, our department has not agreed upon a clear protocol about how to label and handle intraspinal catheters. Further, education on spinal catheters had not been provided to anesthesia and other labor and delivery staff. Until this has been achieved, we feel that despite the numerous publications stating the safety of intrathecal catheters, we are just not in the “right place” as yet.
Situational awareness errors contribute to a large proportion of anesthesia-related adverse events.6 Understanding how and if results from the current literature can be safely translated into daily practice should be part of the discussion we have to have with our residents as well as within departments.
- Velickovic I, Pujic B, Baysinger CW, et al. Continuous spinal anesthesia for obstetric anesthesia and analgesia. Front Med (Lausanne)2017;4:133.
- Tien, M., Peacher DF, Franz AM, et al. Failure rate and complications associated with the use of spinal catheters for the management of inadvertent dural puncture in the parturient: a retrospective comparison with re-sited epidural catheters. Curr Med Res Opin 2016;32:841–846.
- Practice guidelines for the prevention, detection, and management of respiratory depression associated with neuraxial opioid administration: an updated report by the American Society of Anesthesiologists Task Force on neuraxial opioids and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology2016;124: 535–552. http://anesthesiology.pubs.asahq.org/article.aspx?articleid=2477976
- Practice guidelines for obstetric anesthesia: an updated report by the American Society of Anesthesiologists task force on obstetric anesthesia. Anesthesiology 2007;106:843-863. Available at http://anesthesiology.pubs.asahq.org/article.aspx?articleid=1923100. Accessed December 9, 2017.
- Ting HY, Tsui BC. Reversal of high spinal anesthesia with cerebrospinal lavage after inadvertent intrathecal injection of local anesthetic in an obstetric patient. Canadian Journal of Anaesthesia2014;61:1004–1007.
- Schulz CM, Burden A, Posner KL, et al. Frequency and type of situational awareness errors contributing to death and brain damage: a closed claims analysis. Anesthesiology 2017;127:326–337.