Scenario in a Nutshell
Subdural catheter in labour.
Stage 1: Assessment and management of inadequate epidural.
Stage 2: Horner’s syndrome and high patchy sensory block develops following epidural bolus.
Target Learner Groups
Anaesthetists and midwifery staff. Useful scenario for anaesthetists new to obstetrics.
| Specific learning opportunities |
|---|
| Demonstrate sensory and motor assessment following insertion of labour epidural |
| Recognise features of a potential subdural catheter |
| Demonstrate appropriate management of a suspected subdural catheter and its complications |
| Suggested learners (to represent their normal roles) | In the room from the start | Available when requested |
|---|---|---|
| Anaesthetic CT2 or ST3+ | √ | |
| Midwife caring for patient | √ | |
| Suggested facilitators | ||
| Faculty to play role of husband | √ | |
| Faculty to play role of daytime anaesthetist finishing shift, handing over the case to the night team | √ |
Details for Facilitators
Patient Demographics
Name: Hannah Age: 32 Gestation: Term + 10 Booking weight: 78 kg Parity: P0 |
Scenario Summary for Facilitators
Patient is on delivery suite having an induction of labour, on IV syntocinon, for post maturity. She had an epidural sited (for labour analgesia) at the level L2–3 by the daytime team. The procedure was difficult, with bony obstruction on multiple attempts. 5 cm of catheter have been left in the space.
45 minutes following an initial 15 ml bolus of 0.1% bupivacaine with 2 μg/ml fentanyl, the patient is still complaining of pain.
On assessment, she has a sensory block to cold to T11 on the right and L1 on the left, with bilateral Bromage score of 0.
Patient very keen for further epidural top-up.
On administration of a further epidural bolus, the patient complains of ongoing labour pains and a strange sensation in her face.
She has a subdural catheter with a high patchy sensory block to T2 right, T4 left and right-sided Horner’s syndrome.
The scenario ends with the description of subsequent management of the patient.
Set-up Overview for Facilitators
| Clinical setting | In a delivery room, on a delivery bed |
| Patient position | Semi-recumbent |
| Initial monitoring in place | Pulse oximeterNIBP cuffCTG |
| Other equipment | 16G cannula dorsum left hand attached to 1 litre Hartmann’s solution at 80 ml/h and 10 IU syntocinon in 500 ml normal saline running at 48 ml/hEpidural catheter secured to back and attached to an epidural pump |
Useful manikin functions | Pupillary accommodation |
Medical Equipment
For core equipment checklist, see Chapter 9.
| Additional equipment specific to scenario | ||
|---|---|---|
| Epidural pump and epidural catheter | Local anaesthetics as per local epidural policy with syringes and drawing-up needles | Syntocinon infusion with infusion pump and giving set |
| Ethyl chloride spray | Pen torch | |
Information Given to the Learners
| Information given to the anaesthetic trainee and midwife caring for the patient by the daytime anaesthetist finishing shift (played by a facilitator). |
| SBAR handover is as follows: |
| Situation: This is Hannah. She has ongoing pain from labour despite me siting an epidural. |
| Background: 32 years old, fit and well primip having IOL for post maturity, 6 cm dilated, on IV syntocinon with normal CTG. |
| Epidural was very difficult to site, multiple bony obstructions but I managed to get it in at L2–3, 5 cm catheter left in space. I administered a total of 15 ml 0.1% bupivacaine with 2 μg/ml fentanyl (or local anaesthetic as per local guidance) 40 min ago and commenced the pump at the standard labour patient-controlled epidural analgesia (PCEA) settings. |
| Assessment: She still has pain 40 min after her loading dose. |
| Recommendation: Are you able to review her epidural? |
Scenario Schedule
Suggested Topics for Debrief Discussion
Where do you think the epidural catheter was?
What made you think that?
Discussion
Anatomy of the Subdural Space
Subdural blocks are a rare complication and are caused by the injection of local anaesthetic into the subdural space. They can occur as an unintended complication of both epidurals and spinals. In spinals, the needle is thought to breach the dura and the arachnoid mater and some local anaesthetic is injected into each.
The subdural space (Figure 20.1) is thought of as a potential space. It is filled with a small amount of serous fluid and lies between the dura and arachnoid mater. The space extends from the second sacral vertebra into the cranial cavity contrasting with the epidural space which ends at the foramen magnum (Ajar et al., 2002). The subdural space is larger both laterally and dorsally (Agarwal et al., 2010). It extends over the dorsal nerve roots and the dorsal root ganglion but is attached to the ventral nerve roots, which explains why the anterior nerve roots (motor and sympathetic nerve fibres) are spared (see clinical features below) (Agarwal et al., 2010).
