15
Rieker Wake Forest Univ. 00:41 1 Epidural Analgesia When bad catheters happen to good anesthetists. Michael Rieker, DNP, CRNA, FAAN Director, Nurse Anesthesia Program Wake Forest School of Medicine History of Epidural Catheters 1901 First epidural injection 1931 Aburel- silk ureteral catheter for OB 1930 – 1950: random materials available to individual practitioner 1950-1960: 1mm PVC cut from industrial roll and sterilized. 1962: Lee’s catheter-smooth tip, side hole @ 1cm Safer than general (?)… but not without risk 145,550 epidurals administered intravascular injection = 1 in 5,000 (0.02%) intrathecal injection = 1 in 2,900 (0.035%) subdural injection = 1 in 4,200 (0.024%) high or total spinal block = 1 in 16,200 (0.006%) Jenkins JG. Some immediate serious complications of obstetric epidural analgesia and anaesthesia: a prospective study of 145,550 epidurals. International Journal of Obstetric Anesthesia. 14(1):37-42, 2005 Jan. Safer than general (?)… but not without risk 19,259 deliveries; neuraxial labor analgesia rate was 75%; overall failure rate was 12% After adequate initial placement, 6.8% required replacement. (1.5% had multiple replacements) Intravenous placement- 6% (46% were made functional) Wet tap-1.2% The incidences of overall failure, intravenous catheter, wet tap, inadequate analgesia and catheter replacement were lower in patients receiving combined spinal-epidural analgesia. For cesarean section, 7.1% of pre-existing labor epidural catheters failed and 4.3% of patients required conversion to general anesthesia. Spinal anesthesia for cesarean section had a lower failure rate of 2.7%, with 1.2% of the patients requiring general anesthesia. Pan PH. Bogard TD. Owen MD. Incidence and characteristics of failures in obstetric neuraxial analgesia and anesthesia: a retrospective analysis of 19,259 deliveries. [Journal Article] International Journal of Obstetric Anesthesia. 13(4):227-33, 2004 Oct. Our goals: Pick a winner Get it in Keep it in Make it work Respond when it goes in the wrong place Pull it out Our goals: Pick a winner Get it in Keep it in Make it work Respond when it goes in the wrong place Pull it out

History of Epidural Catheters Epidural AnalgesiaEpidural Analgesia When bad catheters happen to good anesthetists. Michael Rieker, DNP, CRNA, FAAN Director, Nurse Anesthesia Program

  • Upload
    others

  • View
    3

  • Download
    0

Embed Size (px)

Citation preview

Page 1: History of Epidural Catheters Epidural AnalgesiaEpidural Analgesia When bad catheters happen to good anesthetists. Michael Rieker, DNP, CRNA, FAAN Director, Nurse Anesthesia Program

Rieker Wake Forest Univ. 00:41

1

Epidural Analgesia

When bad catheters happen to good anesthetists.

Michael Rieker, DNP, CRNA, FAANDirector, Nurse Anesthesia Program

Wake Forest School of Medicine

History of Epidural Catheters

1901 First epidural injection

1931 Aburel- silk ureteral catheter for OB

1930 – 1950: random materials available to individual practitioner

1950-1960: 1mm PVC cut from industrial roll and sterilized.

1962: Lee’s catheter-smooth tip, side hole @ 1cm

Safer than general (?)… but not without risk

145,550 epidurals administered intravascular injection = 1 in 5,000 (0.02%) intrathecal injection = 1 in 2,900 (0.035%) subdural injection = 1 in 4,200 (0.024%) high or total spinal block = 1 in 16,200 (0.006%)

Jenkins JG. Some immediate serious complications of obstetric epidural analgesia and anaesthesia: a prospective study of 145,550 epidurals. International Journal of Obstetric Anesthesia. 14(1):37-42, 2005 Jan.

Safer than general (?)… but not without risk

19,259 deliveries; neuraxial labor analgesia rate was 75%; overall failure rate was 12%

After adequate initial placement, 6.8% required replacement. (1.5% had multiple replacements)

Intravenous placement- 6% (46% were made functional) Wet tap-1.2% The incidences of overall failure, intravenous catheter, wet tap,

inadequate analgesia and catheter replacement were lower in patients receiving combined spinal-epidural analgesia.

For cesarean section, 7.1% of pre-existing labor epidural catheters failed and 4.3% of patients required conversion to general anesthesia. Spinal anesthesia for cesarean section had a lower failure rate of 2.7%, with 1.2% of the patients requiring general anesthesia.

Pan PH. Bogard TD. Owen MD. Incidence and characteristics of failures in obstetric neuraxial analgesia and anesthesia: a retrospective analysis of 19,259 deliveries. [Journal Article] International Journal of Obstetric Anesthesia. 13(4):227-33, 2004 Oct.

Our goals:

Pick a winner

Get it in

Keep it in

Make it work

Respond when it goes in the wrong place

Pull it out

Our goals:

Pick a winner Get it in

Keep it in

Make it work

Respond when it goes in the wrong place

Pull it out

Page 2: History of Epidural Catheters Epidural AnalgesiaEpidural Analgesia When bad catheters happen to good anesthetists. Michael Rieker, DNP, CRNA, FAAN Director, Nurse Anesthesia Program

Rieker Wake Forest Univ. 00:41

2

Types of Catheters Types of Catheters

Material Polyamide Nylon (Braun, Portex) Spring wound polyurethane polymer (Arrow) Hybrid (Braun Soft-tip)

Orifices Single end hole Multiple side holes

Nylon catheters

Greater tensile strength

More often associated with multiple side orifices

Stiff

Greater incidence of venous cannulations, paresthesias

Soft catheters

Greater ease of threading Resistant to kinking Less paresthesias and vein cannulations Some require stylet Usually with single orifice More likely to curl Weaker; prone to becoming lodged, separated,

and possibly broken upon withdrawal

Arrow Flex-Tip Cath Catheter comparison

Portex Arrow(Soft)

Paresthesia 39 3

Vein Cannulation 11 0

Inability to insert 5 (*ns) 0

Page 3: History of Epidural Catheters Epidural AnalgesiaEpidural Analgesia When bad catheters happen to good anesthetists. Michael Rieker, DNP, CRNA, FAAN Director, Nurse Anesthesia Program

Rieker Wake Forest Univ. 00:41

3

Catheter Strength

Asai T, Yamamoto K, Hirose T, Taguchi H, et al. Breakage of epidural catheters: a comparison of an arrow reinforced catheter and other nonreinforced catheters. Anesth Analg 2001; 92: 246–8

Manufacturer Reported malfunctions 1991-2004

Arrow 248

Braun 114

Abbott 75

Baxter 31

Smith 25

Portex 20

Epimed 17

Becton Dickson 2

“Hybrid” catheter- Braun Soft-tip

Multi-orifice catheters

Better spread

Potential for Multi-compartmental or partial block

Unilateral block half as frequent than with single-orifice catheters (8% vs. 16%)

Dickson MA. Moores C. McClure JH. Comparison of single, end-holed and multi-orifice extradural catheters when used for

continuous infusion of local anaesthetic during labour. British Journal of Anaesthesia. 79(3):297-300, 1997 Sep.

Significantly less unilateral block or unblocked segments

Segal S. Eappen S. Datta S. Superiority of multi-orifice over single-orifice epidural catheters for labor analgesia and cesarean delivery. Journal of Clinical Anesthesia. 9(2):109-12, 1997 Mar.

Multi-orifice catheters

Page 4: History of Epidural Catheters Epidural AnalgesiaEpidural Analgesia When bad catheters happen to good anesthetists. Michael Rieker, DNP, CRNA, FAAN Director, Nurse Anesthesia Program

Rieker Wake Forest Univ. 00:41

4

D. McAtamney, C. O'hare, J. P. H. Fee An in vitro evaluation of flow from multiholeepidural catheters during continuous infusion with four different infusion pumps Anaesthesia 1999;54(7):664–669

D. McAtamney, C. O'hare, J. P. H. Fee An in vitro evaluation of flow from multiholeepidural catheters during continuous infusion with four different infusion pumps Anaesthesia 1999;54(7):664–669

To work well, a continuous infusion pump has to act like a

bolus infusion device.

Single-orifice catheters

Better spread to sacrum “...epidural catheter design does affect the distribution of

solutions in the epidural space. Single orifice epidural catheters compared favourably with multi-orifice catheters, resulting in more even distribution and sacral extension of dye.”

Magides AD. Sprigg A. Richmond MN. Lumbar epidurography with multi-orifice and single orifice epidural catheters. Anaesthesia. 51(8):757-63, 1996 Aug.

Our goals:

Pick a winner

Get it in Keep it in

Make it work

Respond when it goes in the wrong place

Pull it out

Does position matter?

~100 patients each sitting or lateral

Vein cannulation 16% in sitting vs. 4% in lateral position

Bigat Z. Boztung N. Onder G. Ertok E. A rare complication of epidural catheter. Acta Anaesthesiologica Scandinavica. 49(4):589-90, 2005.

Are all spaces created equally?

Page 5: History of Epidural Catheters Epidural AnalgesiaEpidural Analgesia When bad catheters happen to good anesthetists. Michael Rieker, DNP, CRNA, FAAN Director, Nurse Anesthesia Program

Rieker Wake Forest Univ. 00:41

5

Brown D. Atlas of Regional Anesthesia.W.B. Saunders, 1992; pg 290

Where do catheters go?Where do catheters go?

Deviation from midline more likely vein cannulation or paresthesia.

20% of catheter tips lay outside the lateral margins of the vertebral bodies

Lateral foramen- catheter deviation r/t distance inserted.

Where do catheters go?

Catheters track more straight into space if inserted at 50º vs. 90º

Takeyama K. Yamazaki H. Maeda M. Tomino K. Suzuki T. Tokai Journal of Experimental & Clinical Medicine. 29(2):27-33, 2004 Jun.

Insertion vs. coiling

Fluoroscopy, paramedian approach

Started at T9; reached to either T6-7 (obtuse 60%) or T7-8

(acute-40%)

Ryu HG. Bahk JH. Lee CJ. Lim YJ. The coiling length of thoracic epidural catheters: the influence

of epidural approach angle. British Journal of Anaesthesia. 2007;98(3):401-4.

Coiling Length Acute Obtuse

Mean 4.9 7.4

Min-Max 95% CI 3.8-6 6-8.7

Ryu HG. Bahk JH. Lee CJ. Lim YJ. The coiling length of thoracic epidural catheters: the influence of epidural approach angle. British

Journal of Anaesthesia. 2007;98(3):401-4.

Page 6: History of Epidural Catheters Epidural AnalgesiaEpidural Analgesia When bad catheters happen to good anesthetists. Michael Rieker, DNP, CRNA, FAAN Director, Nurse Anesthesia Program

Rieker Wake Forest Univ. 00:41

6

“False loss of resistance”

Out of sight… out of epidural space?

Lateral catheter = unilateral block

Double, double, Coil and trouble

Coil / knot

Arrow: 7 cephalad

3 caudad

1 same space

Portex 3 cephalad

3 same

1 caudad

Martin R. Pirlet M. Parent M. Gingras F. Evaluation of epidural catheter tip position. Canadian Journal of Anaesthesia. 50(9):963; 2003 Nov.

Double, double, Coil and trouble

19ga Arrow Flex-Tip in 45 patients

median coiling length- 2.8 cm (1.0–8.0 cm)

Only 6 (13%) threaded >4 cm without coiling

Page 7: History of Epidural Catheters Epidural AnalgesiaEpidural Analgesia When bad catheters happen to good anesthetists. Michael Rieker, DNP, CRNA, FAAN Director, Nurse Anesthesia Program

Rieker Wake Forest Univ. 00:41

7

Double, Double, Coil and Trouble

Pain & sensory loss in thigh

Catheter coiled around L3 nerve root

Stretched and broke on withdrawal

Double, Double, Coil and Trouble

Catheter inserted 9 cm.

Resistance on withdrawal. Steady pressure finally removed catheter (somewhat painfully)

Brichant, J.F., Bonhomme, V. and Hans P. (2006) On knots in epidural catheters: a case report and a review of the literature International Journal of Obstetric Anesthesia15(2): 159-162

Double, Double, Coil and Trouble

Catheter inserted 8 cm.

Attempt to pull back to 5cm met with resistance.

Knot and loop found at 7.5cm Huang, J. Another case of knotting of an epidural catheter. AANA J. 2010;78(2):93-94.

Double, double, Coil and trouble

Looping doesn’t always occur in the patient

Where do catheters go, Up or down?

Direction of insertion does not make much of a difference.

45 patients. Surgery affecting sacral nerves

Catheters: half up; half down.

No difference in onset time, duration, anesthetic level, and analgesic effect

Liu CC. Chau SW. Spielberger J. Liu PH. Chou WY. Tan PH. Evaluation of the effects of caudal or cephalic epidural catheterization on the characteristics of lumbar epidural anesthesia. Acta Anaesthesiologica Taiwanica: Official Journal of the Taiwan Society of Anesthesiologists. 43(2):79-83, 2005

Catheter shearing

Don’t withdraw through needle

Patient movement may cause shearing Noblett, Karen (02/2007). "Sheared epidural catheter during

an elective procedure." Obstetrics and gynecology, 109 (2), p. 566.

Page 8: History of Epidural Catheters Epidural AnalgesiaEpidural Analgesia When bad catheters happen to good anesthetists. Michael Rieker, DNP, CRNA, FAAN Director, Nurse Anesthesia Program

Rieker Wake Forest Univ. 00:41

8

Improving technique

Ultrasound guidance to find ES in pediatric patients.

US correlated 0.88 with conventional LOR Rapp HJ. Folger A. Grau T. Ultrasound-guided epidural catheter insertion in children. Anesthesia &

Analgesia. 101(2):333-9, table of contents, 2005

Ultrasound estimation of depth significantly improved placement rate

Vallejo MC et al, Ultrasound decreases the failed labor epidural rate in resident trainees, Int J Obstet Anesth 19(4):373-8, 2010.

Our goals:

Pick a winner

Get it in

Keep it in Make it work

Respond when it goes in the wrong place

Pull it out

Disconnection

Variety of connectors available.

Careful with caustic antiseptics

If meniscus moves/moved- whole cath may be contaminated

2% would reconnect

15% clean the outside and reconnect

4% would cut and reconnect

44% would clean, cut,and reconnect

35% would remove the catheter.

Disconnection

Disconnection Disconnection

Page 9: History of Epidural Catheters Epidural AnalgesiaEpidural Analgesia When bad catheters happen to good anesthetists. Michael Rieker, DNP, CRNA, FAAN Director, Nurse Anesthesia Program

Rieker Wake Forest Univ. 00:41

9

Disconnection Statlock Device

Secured to skin or epidural space?

Lockit device holds catheter securely at skin.

Reduces, but does not prevent movement-related failure

Epidural failure

125 patients with surgical epidurals 25% failed. 45% of failed due to dislodgement

Motamed, Cyrus (2006). "An analysis of postoperative epidural analgesia failure by computed tomography epidurography.". Anesthesia and analgesia 103 (4), p. 1026.

Where do catheters go?

Pull out-

Skin to epidural space distance increases when sitting lateral.

Most pronounced in obese.

Hamilton CL. Riley ET. Cohen SE. Changes in the position of epidural catheters associated with patient movement. Anesthesiology. 86(4):778-84; discussion 29A, 1997 Apr.

Our goals:

Pick a winner

Get it in

Keep it in

Make it work Respond when it goes in the wrong place

Pull it out

Page 10: History of Epidural Catheters Epidural AnalgesiaEpidural Analgesia When bad catheters happen to good anesthetists. Michael Rieker, DNP, CRNA, FAAN Director, Nurse Anesthesia Program

Rieker Wake Forest Univ. 00:41

10

Air or saline for LOR?

A 31- year old primip with L3-L4 labor epidural. 4 hours after catheter placement- constant, severe, sharp, bilateral subscapular back pain with radiation to left shoulder and arm that started acutely after pressing the PCEA button

Space Occupying Epidural Air Necessitating Emergent Caesarean Delivery. Chaim Golfeiz, Michael W. Best, Manuel C. Vallejo. BJA Aug 14, 2013

Why do they stop working? Why do they stop working?

101 parturients studied 20 % required conversion to general anesthesia. Reasons for failure:

Younger parturient age (P = 0.014) higher pre-pregnancy weight (P = 0.019) Higher weight at the end of pregnancy (P = 0.003) higher body mass index (P = 0.0004) gestational week (P = 0.008) number of top-ups (P = 0.0004) visual analog scale (VAS) score 2 h before CS (P = 0.03).

Acta Anaesthesiologica Scandinavica. 50(7):793-7, 2006 Aug.

What if it’s “iffy”?

Important to calculate depth in epidural space.

For patchy block, add bolus; if no relief, withdraw catheter 1cm

Maintain at least 3 cm in space for multi; at least 2 cm for single orifice.

Our goals:

Pick a winner

Get it in

Keep it in

Make it work

Respond when it goes in the wrong place

Pull it out

Intravenous Placement

Lateral situation?

Collapsible- test passive aspiration

Appropriate to withdraw, flush, salvage

Expand space- 2% vs. 16% incidence of venous placement Evron, et al. A & A. 2007;105(2)460.

Pre-flushed catheter- takes 2x as long to identify IV placement Bell, O'Connor & Leslie.. Anaesthesia & Intensive Care. 35(6):932-8,

2007

Unintentional IV Injection

HR 20-30 bpm (epinephrine)

Patient complaints:

“ringing” in the ears

dizziness

tinnitus

circumoral numbness

*Initial study used non pregnant patients

Page 11: History of Epidural Catheters Epidural AnalgesiaEpidural Analgesia When bad catheters happen to good anesthetists. Michael Rieker, DNP, CRNA, FAAN Director, Nurse Anesthesia Program

Rieker Wake Forest Univ. 00:41

11

Speaking of Intravenous Placement… test dose

Isoproterenol to avoid α- effect of epi

HR response non-specific in labor

Careful about multiple repeats

With dilute solutions following CSE, test for IT placement only

T-wave changes

Speaking of Intravenous Placement… test dose

Meniscus test Inject air, then saline Hold catheter up Dropping meniscus = epidural placement

Hold catheter down Continuing flow = subarachnoid or vein Return of bubbles + outflow that stops =

epidural

Bosseau Murray W. Trojanowski A. A nonpharmacological three-step test for confirmation of correct epidural catheter placement. Anesthesia & Analgesia. 87(5):1216-7, 1998 Nov

Where do catheters go?

Subdural- high, patchy block, horner’s syndrome; multi-compartmental catheter

Subdural catheter- Railroad Tracks

Subdural catheter-Railroad Tracks

Characteristics of Subdural placement Regional Anesthesia and Pain Medicine January-February 2009

Page 12: History of Epidural Catheters Epidural AnalgesiaEpidural Analgesia When bad catheters happen to good anesthetists. Michael Rieker, DNP, CRNA, FAAN Director, Nurse Anesthesia Program

Rieker Wake Forest Univ. 00:41

12

Characteristics of Subdural placement Regional Anesthesia and Pain Medicine January-February 2009

Characteristics of Subdural placement

Excessive spread of block with: Slow onset > 20 min.

CV instability

Motor sparing with sensory block

Patchy/asymetrical block

Respiratory failure

Facial/head involvement

Hoftman NN, Ferrants MF. Diagnosis of Unintentional Subdural Anesthesia/Analgesia: Analyzing RadiographicallyProven Cases to Define the Clinical Entity and to Develop a Diagnostic Algorithm. Reg Anesth Pain Med 2009;34(1):12-16.

Where do catheters go?

Through dura

Contrary to intuition, CSE does not increase subdural placement.

100 patients; eposcan vs. conventional touhy. No dural puncture of catheter

Browne IM. Birnbach DJ. Stein DJ. O'Gorman DA. Kuroda M. A comparison of Espocan and Tuohy needles for the combined spinal-epidural technique for labor analgesia. Anesthesia & Analgesia. 101(2):535-40, table of contents, 2005

Where do catheters go?

Subarachnoid Portex Arrow

Intact dura 0/300 0/300

Occult 17ga hole

1/14 0/15

Obvious 17ga hole

6/33 1/35

25ga CSE 0/90 0/90

Angle PJ. Kronberg JE. Thompson DE. Duffin J. Faure P. Balasubramaniam S. Szalai JP. Cromwell S. Epidural

catheter penetration of human dural tissue: in vitro investigation. Anesthesiology. 100(6):1491-6, 2004 Jun.

Where do catheters go?

Subarachnoid

Decision tree- thread catheter

Anesthesiology. 101(6):1422-7, 2004 Dec.

Pro Con

Unpredictable Danger of misuse Above L3? Infection and injection CES

Effective Avoid risk of 2nd dural puncture Prevent PDPH Obese pt- dependable for C/S

Subarachnoid catheter; What next?

Survey in UK. 176 units. 144 of which have written guidelines

28% place catheter, 31% give option]

Rationale: avoid potential for additional dural puncture and provide immediate analgesia

71%: EBP only after conservative measures fail for PDPH

Baraz R. Collis RE. The management of accidental dural puncture during labour epidural analgesia: a survey of UK practice. Anaesthesia. 60(7):673-9, 2005

Page 13: History of Epidural Catheters Epidural AnalgesiaEpidural Analgesia When bad catheters happen to good anesthetists. Michael Rieker, DNP, CRNA, FAAN Director, Nurse Anesthesia Program

Rieker Wake Forest Univ. 00:41

13

Where do catheters go?

Subarachnoid Catheter vs. PDPH

Efficacy increases with duration left inStrategy PD PH

IncidenceReplaceepidural

80%

IT catheter,rem oved @

delivery30%

IT catheter,left for 24

hours3%

Ayad S. Demian Y. Narouze SN. Tetzlaff JE. Subarachnoid catheter placement after wet tap for analgesia in labor: influence on the risk of headache in obstetric patients. Regional Anesthesia & Pain Medicine. 28(6):512-5, 2003 Nov-Dec.

Responding to Problems

Intrathecal “epidural” catheter

intrathecal injection possibly 200 mg of lidocaine and 61 mg of bupivacaine

apnea and fixed dilated pupils

20ml cerebrospinal fluid was replaced with 10 mL of NS and 10 mL of LR

Spontaneous respiration 5 min later, extubated in 30 min. No deficits or PDPH

Responding to Problems

Inadvertant intrathecal drugs (bupivacaine, lido, chloroprocaine) all associated with cauda equina syndrome.

Immediate injection of 10ml PF saline will help to dilute and has been shown to decrease incidence of subsequent PDPH.

Inadvertent subarachnoid injection

Tsui, Ban C. H. MD, MSc, FRCP(C)*; Malherbe, Stephan MB, ChB, MMed, FCA(SA)*; Koller, John MD, FRCP(C)*; Aronyk, Keith MD, FRCS(C)† Anesthesia & Analgesia (2004) 98(2) 434-43Reversal of an Unintentional Spinal Anesthetic by Cerebrospinal Lavage

Ferayan AA, Russell NA, Wohaibi MA, et al. Cerebrospinal fluid lavage in the treatment of inadvertent intrathecal vincristine injection. Childs Nerv Syst 1999; 15: 87–9

Charsley MM, Abram SE. The injection of intrathecal normal saline reduces the severity of postdural puncture headache. Reg Anesth Pain Med 2001; 26: 301–5.

Our goals:

Pick a winner

Get it in

Keep it in

Make it work

Respond when it goes in the wrong place

Pull it out

What goes up must come down; what goes in...

Removal complications

Arrow catheter stretches significantly more and breaks at lower weight than nylon

Asai T, Yamamoto K, Hirose T, Taguchi H, et al. Breakage of epidural catheters: a comparison of an arrow reinforced catheter and other nonreinforced catheters. Anesth Analg 2001; 92: 246–8

Soft catheters appear in numerous case reports lodged/unable to be removed

Page 14: History of Epidural Catheters Epidural AnalgesiaEpidural Analgesia When bad catheters happen to good anesthetists. Michael Rieker, DNP, CRNA, FAAN Director, Nurse Anesthesia Program

Rieker Wake Forest Univ. 00:41

14

Reinforced wire catheter problems

Catheter stuck.

Patient placed into the left lateral decubitus position and the catheter was removed without difficulty.

However, it was noted that the catheter reinforcing wire had become uncoiled at the distal end and remained inside the patient

The wire was successfully withdrawn with steady traction

Bastien JL. McCarroll MG. Everett LL. Uncoiling of Arrow Flextip plus epidural catheter reinforcing wire

during catheter removal: an unusual complication. Anesthesia & Analgesia. 98(2):554- 5, 2004

What goes up must come down; what goes in…???

Wires uncoil

What goes up must come down; what goes in...

Inadvertant intrathecal placement, with inability to remove catheter immediately after placement.

Epidural placement with immediate attempt to withdraw, but unable.

Catheter left in place for 3 days, with daily attempts to remove, until finally removed

Asai T. Shingu K. Advantages and disadvantages of the Arrow FlexTip Plus epidural catheter. Anaesthesia. 56(6):606, 2001

What goes up must come down; what goes in...

Patient in lateral position for withdrawal. Resistance felt before catheter broke without any significant stretching.

Ugboma S. Au-Truong X. Kranzler LI. Rifai SH. Joseph NJ. Salem MR. The breaking of an intrathecally-placed epidural catheter during extraction. Anesthesia & Analgesia. 95(4):1087-9, table of contents,

Allowed the patient to relax for 3 hours, placing the patient in the lateral decubitus position, and placing continuous tension on the catheter itself so as to let it "work its way out".

Pierre HL. Block BM. Wu CL. Difficult removal of a wire-reinforced epidural catheter Journal of Clinical Anesthesia. 15(2):140-1, 2003 Mar.

What goes up must come down; what goes in...

Catheter began to distort at 7cm

Small incision, grasped at 6cm

Had pt twist her hips

Asai T. Sakai T. Murao K. Kojima K. Shingu K. More difficulty in removing an arrow epidural catheter. Anesthesia & Analgesia. 102(5):1595-6, 2006 May.

What goes up must come down; what goes in…???

Case reports: Catheter placed intrathecally; inability to remove

immediately

Catheter placed normally; inability to withdraw for depth immediately Difficulty persisted for 3 days until finally removed

Catheter pulled with hemostat- broke at grip site

Page 15: History of Epidural Catheters Epidural AnalgesiaEpidural Analgesia When bad catheters happen to good anesthetists. Michael Rieker, DNP, CRNA, FAAN Director, Nurse Anesthesia Program

Rieker Wake Forest Univ. 00:41

15

Measures to remove entrapped catheter

Don’t force Gently tighten knot Lateral position or same as insertion Don’t use instruments Give “rest time” (hours or days) Steady, progressive traction Injection of saline to R/O knot GA with muscle relaxants

Arrow Flex-tip catheter

Summary

In spite of safety with regional techniques, proper placement of epidural catheters can be challenging, even in cases of uneventful insertion.

Avoid complications Distend space with saline Lateral position/soft tip to reduce vein cannulation CSE for placement verification Limit insertion depth

Secure to non-moveable anchor, but not before soft tissue shifts Recognize limitations of test doses/Every dose is a “test dose” Intrathecal placement now more commonly left in place instead

of replaced

Summary

Soft catheters reduce intravascular placement and paresthesias, but are more likely to become lodged and subsequently break

High index of suspicion for catheter failure break-through pain/spotty block Lots of top-up doses Large patient size

Lodged catheters should be removed conservatively Lateral position Gentle, steady pressure Position change Saline injection