512 Correspondence

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endotracheal intubation. Indian J Anaesth 2011; 55:451–455.
2 Agro F, Sena F, Lobo E, et al. The Dexter Endoscopic Dexterity Trainer Reading, USA) were inserted, before surgery, with a
improves fibreoptic bronchoscopy skills: preliminary observations. Can J 17/18-gauge Rodiera or 17-gauge Tuohy needle through
Anesth 2005; 52:215–216.
3 Marsland C, Larsen P, Segal R, et al. Proficient manipulation of fibreoptic
the thoracic intervertebral spaces using the loss-of-resist-
bronchoscope to carina by novices on first clinical attempt after specialized ance technique. The correct catheter placement was
bench practice. Br J Anaesth 2010; 104:375–381. evaluated with the aspiration test and with the infusion
4 Martin KM, Larsen PD, Segal R, Marsland CP. Effective non-anatomical
endoscopy training produces clinical airway endoscopy proficiency. Anesth
of 3 ml 1% mepivacaine with epinephrine 1 : 200 000 in
Analg 2004; 99:938–944. order to exclude intrathecal or intravascular placement.
5 Boet S, Bould MD, Schaeffer R, et al. Learning fibreoptic intubation with a
virtual computer program transfers to ’hands on’ improvement. Eur J Logistic regression was performed to ascertain the effects of
Anaesthesiol 2010; 27:31–35.
risk factors on the likelihood that patients had a minor
complication at catheter positioning. We analysed age,
DOI10.1097/EJA.0000000000000091
sex, BMI, patient’s position during puncture (sitting vs.
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lateral decubitus), needle (Tuohy vs. Rodiera), puncture

Minor complications during thoracic epidural
catheter placement
Federico Piccioni, Silvia Luisa Bernardelli, Claudia Casiraghi
and Martin Langer
From the Department of Anaesthesia, Intensive Care and Palliative Care,
Fondazione IRCCS Istituto Nazionale dei Tumori (FP, ML), School of Anaesthesia
and Intensive Care (SLB, CC), and Department of Pathophysiology and
Transplantation, University of Milan, Milan, Italy (ML)
Correspondence to Dr Federico Piccioni, MD, Department of Anaesthesia,
Intensive Care and Palliative Care, Fondazione IRCCS Istituto Nazionale dei
Tumori, Via Venezian 1, Milan 20133, Italy
Tel: +39 0223902282; fax: +39 0223903366;
e-mail: federico.piccioni@istitutotumori.mi.it
Published online 13 February 2015
Editor,
Epidural analgesia is considered the gold standard
analgesic technique for postoperative acute pain manage-
ment after major surgery.1 Although major complications
(epidural haematoma and permanent neurological injury)
have been widely investigated,2–4 a lack of overview on
minor complications and related risk factors was found.
Most commonly reported minor complications during
thoracic epidural catheter placement include bloody
punctures (1.7%), dural perforation (0.8%), paraesthesia
(0.5%), malposition (7.1%), disconnection (0.6%) and
occlusion (0.4%).2 We investigated the occurrence of
minor complications and related risk factors during thor-
acic epidural catheter placement.
Ethical approval for this study (Protocol INT150-12) was
provided by the Independent Ethics Committee of the
Fondazione IRCCS Istituto Nazionale dei Tumori of
Milan, Italy (chairman Dr Roberto Satolli) on 17
December 2012.
Data concerning patients undergoing thoracic epidural
analgesia from November 2008 to December 2012 at our
institution were reviewed. All data were retrieved from
our electronic prospectively maintained Acute Pain Ser-
vice database (installed on a handheld device).
approach (median vs. lateral), level of thoracic puncture
(grouped as follows: high level T3-T7, mid T7-T10, low
T10-L1), type of catheter (normal vs. reinforced) and anaes-
thesiologist (staff anaesthesiologists vs. residents) as risk
factors for minor complications at epidural catheter position-
ing. A P value of less than 0.05 was considered as statistically
significant. Data analysis was carried out with IBM SPSS
Statistics v.21 (IBM Corporation, Armonk, New York, USA).
We obtained data on 2084 patients, finding 124 place-
ments with minor complications (Table 1), showing an
overall incidence of 5.95% [95% confidence interval (95%
CI) 4.93 to 6.97)].
To our knowledge, no patients developed neurological
sequelae after radicular symptoms or bloody puncture
during catheter positioning. No patients developed a
clinically evident epidural haematoma after the pro-
cedure. When the catheter did not advance in the epi-
dural space, it was successfully positioned at another
intervertebral level. Five out of 23 patients (21.7%)
suffered postdural puncture headache. Only one patient
received a blood-patch treatment immediately after dural
puncture and did not develop a headache. Fainting
occurred more frequently in younger patients [mean
age: 51.9 (95% CI 39.7 to 64.1) vs. 61.2 (95% CI 60.8
to 62.0); P ¼ 0.037]. Logistic regression showed a higher
risk of difficult catheter progression in the epidural space
during staff anaesthesiologists’ attempts than residents’
efforts (odds ratio 4.37; 95% CI 1.03 to 18.52; P ¼ 0.046).
The paramedian puncture approach showed a greater
association with intraoperative catheter occlusion than
the median one (odds ratio 3.58; 95% CI 1.25 to 10.27;
P ¼ 0.017). No other risk factors were found to be sig-
nificant for minor complications.
We observed a rather high overall incidence of minor
complications at thoracic epidural catheter placement
(5.95%). Difficult catheter progression in the epidural
space was the most common problem encountered
(1.3%). This occurred more frequently with staff anaes-
thesiologists than residents. However, in our opinion, the
placement by an experienced anaesthesiologist cannot be
considered at all a risk factor for difficult catheter

Eur J Anaesthesiol 2015; 32:506–515

Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.
 Correspondence 513

Table 1 Patient data and minor early complication incidence

% (N) or mean 95% CI (range)

Sex
Male 62.9% (1310)
Female 37.1% (774)
Age (years) 61.3 60.7 to 61.9 (18 to 89)
Weight (kg) 71.4 70.8 to 72.1 (36 to 130)
Height (cm) 168.3 167.9 to 168.6 (138 to 197)
BMI (kg m –2) 25.1 24.9 to 25.3 (15.1 to 45.2)
Intervertebral space level of epidural catheter placement
High (T3-T7) 39.2% (817)
Mid (T7-T10) 56.1% (1169)
Low (T10-L1) 4.7% (98)
Type of complications
Paraesthesia during catheter placement 0.8% (17) 0.4 to 1.2
Difficult catheter progression in the epidural space 1.3% (27) 0.8 to 1.8
No catheter progression in the epidural space 0.5% (10) 0.2 to 0.8
Dural puncture 0.9% (18) 0.5 to 1.3
Leakage of cerebrospinal fluid from catheter 0.2% (5) 0 to 0.4
Bloody puncture 1% (21) 0.6 to 1.4
Lipotimia Fainting during puncture 0.4% (9) 0.1 to 0.7
Intraoperative catheter occlusion 0.8% (17) 0.4 to 1.2
Catheter removal for inadequate efficacy after extubation 2.8% (59) 2.2 to 3.6

CI, confidence interval.

progression, as they often deal with more complicated
patients and, moreover, with failed placements by resi-
dents. Interestingly, when the epidural catheter did not
successfully advance in the epidural space (0.5%), it was
positively placed at another intervertebral space.
Bloody puncture occurred less frequently than reported
by others (1 vs. 1.75%), although we observed a higher
incidence of paraesthesia during catheter insertion (0.8
vs. 0.47%).2 To our knowledge, no patients had perma-
nent neurological injury due to haematoma or radicular
damage. Dural perforation and intrathecal catheter pla-
cement occurred in 0.9 and 0.2% of patients, respectively.
Postdural puncture headaches were observed in 21.7% of
these patients. These data are in line with the literature.2
Surprisingly, the paramedian approach increases the risk
of intraoperative occlusion of the catheter (odds ratio
3.58) despite the fact that the common opinion is that
it offers a wider passage for both the needle and the
catheter. Most of us adopt the paramedian approach if the
median one fails, so it is frequently performed in complex
spine (with arthrosis joint, kyphosis, scoliosis or vertebral
fracture) procedures. It must be noted that adopting a
reinforced catheter did not eliminate the risk of
intraoperative occlusion.
At the end of the surgical procedure, immediately after
extubation, 2.8% of patients reported severe pain even if
the epidural catheter was presumed to be efficient during
general anaesthesia. These data are simple but important
because the patients should be always informed about the
failure rate of an invasive procedure.
This study highlights that the incidence of minor com-
plications related to the placement of a thoracic epidural
catheter are frequent (nearly 6%). Indirectly, we found
that complex spine increases the risk of these compli-
cations. Self-evaluation of minor complications is useful
to correctly assess the risks of epidural catheter place-
ment, to inform patients about it and to improve one’s
skill. Prospective observational studies are needed to
better describe this kind of complications and related
risk factors.
Acknowledgements relating to this article
Assistance with the study: the authors wish to thank their anaes-
thesiologist colleagues Dr Mario Ammatuna, Dr Anna Cardani, Dr
Roberta Casirani, Dr Valerio Costagli, Dr Pasqualina Costanzo,
Dr Ilaria Donati, Dr Giuditta Fallabrino, Dr Luca Fumagalli, Dr
Edward Haeusler, Dr Antonio Maucione, Dr Silvana Migliavacca,
Dr Lucia Miradoli, Dr Andrea Poli, Dr Paola Previtali, Dr Paolo
Proto, Dr Giacomino Rebuffoni, Dr Giuseppe Rigillo, Dr Emiliano
Tognoli and Dr Irene Vecchi for participating in data collection.
Financial support and sponsorship: none.
Conflicts of interest: none.
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DOI:10.1097/EJA.0000000000000225

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