Background and objective In recent studies, ultrasonic diagnostic imaging has proved useful in the screening of the trajectory of the epidural needle. With regard to possible side-effects of spinal and epidural anaesthesia caused by vessel injury, we aimed to evaluate the usability of Colour Doppler imaging for the depiction of interspinous vessels in prepuncture examination.

Methods Ultrasonic examination of the L¾ interspace area was performed in 20 volunteers. Using a 4-MHz and a 7-MHz probe with B-mode and Colour Doppler imaging, respectively, we compared four settings for the quality of vessel depiction in the puncture area. Overall resolution was evaluated according to the distinction of landmarks. Vascular structures were identified by pulsation (B-mode) or blood flow (Doppler).

Results Colour Doppler imaging of the L3/4 interspace was unachievable using the 7-MHz transducer. Vessel detection was possible in 50% of the B-mode images and in all of the 4-MHz Doppler images. Vessels were perceptible from a diameter of 0.5 mm. Veins were the predominantly visible structures. Overall vessel visibility was best using 4-MHz Colour Doppler.

Conclusions Prepuncture Doppler imaging can provide the epiduralist with information regarding the position of vessels in the needle trajectory. This might help to reduce complications in regional anaesthesia.

Von Hippel-Lindau disease is a rare autosomal dominant disease with incomplete penetrance and variable expression and is characterized by diffuse haemangioblastomas of the central nervous system and viscera. The majority of the central nervous system lesions are located in the cerebellum. This report describes the successful management with epidural anaesthesia of a woman with a term gestation, von Hippel-Lindau disease and cerebellar haemangioblastoma.

The effects of intravenous and epidural clonidine, 4 μg kg−1, combined with epidural morphine, 40 μg kg−1, on the neuro-endocrine and immune stress responses to thoracic surgery are reported. A control group received only epidural morphine. Anaesthesia was induced and maintained with propofol. Catecholamines, vasopressin, cortisol, β-endorphin concentrations and leucocyte counts were measured before drug administration, immediately after intubation of the trachea, after thoracotomy and at the end of surgery. Catecholamines did not change in any of the groups. The other stress hormones increased during surgery, the pattern being similar in the three groups. Total leucocyte and neutrophil counts were increased in all groups at the end of surgery, but the increase was least in the epidural clonidine group. The number of lymphocytes was reduced at the end of surgery in the epidural and intravenous group, compared with the control group in which the number of lymphocytes did not change. The effects are more pronounced with epidural than with intravenous administration. We conclude that clonidine can modulate the immune stress response to thoracic surgery.

It has been suggested that epidural anaesthesia may increase blood flow in free flaps on the lower extremity. The objective of the present study was to test this hypothesis in 21 patients undergoing reconstructive surgery of the lower extremity with free muscle (n=8), fasciocutaneous (n=6) or musculocutaneous (n=7) flaps. Microcirculatory blood flow was measured continuously with a multichannel laser Doppler flowmetry, both in muscle and skin of the free flap as well as in the intact skin and muscle on the same extremity. After completion of surgery, general anaesthesia was continued and the epidural block was induced by an injection of 2% lignocaine-hydrochloride into a pre-operatively inserted and tested epidural catheter. The epidural block caused no change in microcirculatory flow in the intact skin and muscle, however, it resulted in a marked decrease in microcirculatory blood flow in all the free flaps studied (20–30%; P < 0.05). The epidural block also caused a significant decrease in mean arterial blood pressure, from 85 (±2.8) mmHg to 68 (±2.8) mmHg (P < 0.01). It was concluded that epidural anaesthesia may decrease microcirculatory blood flow in free flaps on the lower extremity by diverting flow away from the flap to normal intact tissues (a steal phenomenon).

An 85-year-old man with undiagnosed eventration of the left hemidiaphragm had an above-knee amputation under epidural anaesthesia. His post-operative course was stormy with two episodes of cardiovascular collapse. On the third post-operative day, rupture of the left hemidiaphragm was diagnosed, the bowel had herniated into the left hemithorax. It is proposed that the left hemidiaphragm ruptured spontaneously because of muscular weakness secondary to the thoracic segmental blockade associated with lumber epidural anaesthesia.

Familial amyloid polyneuropathy (FAP) type I is a rare disease characterized by sensorimotor polyneuropathy, and autonomic nervous system and cardiac conduction system dysfunction. Severe bradyarrhythmia and hypotension may occur during anaesthesia and surgery in patients with the FAP type I. Only one report has been published of a patient with FAP type I who was managed with epidural anaesthesia. The present authors report a 38-year-old Japanese man with a permanent pacemaker because of advanced FAP type I who underwent rotation flap of the gluteus maximus muscle to cover a trophic ulcer in the sacral region under lumbar epidural anaesthesia. Ten millilitres of adrenaline (1:200 000) was injected around the ulcer prior to surgical manipulation. Neither bradycardia nor hypotension developed during the procedures. The haemodynamic changes under lumbar epidural anaesthesia in FAP type I are discussed.

A healthy 22-year-old man received an initial injection of 12 mL of lignocaine/bupivacaine solutions (2 mL test, then 10 mL) into an epidural catheter. This produced a satisfactory regional blockade that seemed to be epidural but, when a supplementary 6 mL injection was given 1 h later, the patient developed impaired motor function as far as the upper cranial nerves, with loss of pinprick sensation to the shoulder. The emergence of fluid dribbling freely from the catheter prompted measurement of the pressure, which was 36 mmHg. The fluid was proved not to be cerebrospinal fluid (CSF) by the absence of glucose (on dextrostix), by the appearance of turbidity with added thiopentone, and later by microscopy. Slow aspiration of 7 mL of the presumed injectate reduced the pressure in the catheter to 8 mmHg, which promptly reversed the additional excessive blockade, allowing surgery to proceed uneventfully. The retrieval of injectate argues strongly that the catheter tip had found its way subdurally, and the promptness of the reversal with aspiration argues for a mechanical rather than a pharmacological cause for the extensive neurological dysfunction after the second injection. Pressure measurement and aspiration may be helpful in other similar cases.