CASE REPORT
Year : 2020 | Volume
: 6 | Issue : 1 | Page : 90--91
Retained broken epidural catheter: What to do?
Kriti1, Nidhi Arun2, Mukesh Kumar3, Sangeeta Pankaj4,
1 Junior Resident, IGIMS, Patna, India
2 Assistant Professor, Dept. of Anesthesiology, IGIMS, Patna, India
3 Associate Professor, Dept. of General Surgery, IGIMS, Patna, India
4 Professor & Head, Dept. of Gynecologic Oncology, IGIMS, Patna, India
Correspondence Address:
Nidhi Arun
Assistant Professor, Dept. of Anesthesiology, IGIMS, Patna
India
Abstract
Background: Epidural anaesthesia / analgesia is a safe and routinely performed procedure by the anaesthesiologists. Although rare, but there have been many instances of epidural catheter breakage. We present a case report of We present a case report of a 38 years old female posted for vaginal hysterectomy under combined spinal epidural anesthesia. During the procedure, while negotiating the epidural catheter in epidural space, it got sheared off at 5cm mark inside the back. Severed catheter in the back could not be visualized under C- arm digital X ray. Plan for spinal epidural lumbar anesthesia was abandoned and surgery was performed under general anesthesia which was uneventful. CT followed by USG was done to locate the severed catheter on 2nd post-operative day. Severed catheter could not be visualized and surgical removal was not attempted. The patient was informed of the event and counselled to report in case of any adverse symptoms.
Conclusion: We want to convey that surgical removal of retained broken catheter should not be attempted routinely as it could provide more complication than leaving it in situ.
How to cite this article:
Kriti, Arun N, Kumar M, Pankaj S. Retained broken epidural catheter: What to do?.J Indira Gandhi Inst Med Sci 2020;6:90-91
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How to cite this URL:
Kriti, Arun N, Kumar M, Pankaj S. Retained broken epidural catheter: What to do?. J Indira Gandhi Inst Med Sci [serial online] 2020 [cited 2023 Mar 21 ];6:90-91
Available from: http://www.jigims.co.in/text.asp?2020/6/1/90/300750 |
Full Text
Introduction:
Epidural anaesthesia / analgesia is a safe and routinely performed procedure by the anaesthesiologists. Although rare, but there have been many instances of epidural catheter breakage[1]. We present a case report of such an event and what could be done in this scenario.
Case Description:
We present a case report of a 38 years old female, ASA physical status grade 1, who was posted for vaginal hysterectomy under combined spinal epidural anesthesia. After confirming pre-anesthetic checks and obtaining written informed consent, the patient was taken for surgery. Utilizing the loss of resistance technique and under all aseptic precautions, an 18 gauze, 80 mm Tuohy needle was inserted to access the epidural space in L3-L4 intervertebral space in the sitting position. Loss of resistance was felt at 5 cm from the skin and catheter was advanced. A resistance was encountered while advancing catheter at 10 cm at the hub of Tuohy needle. To relocate the epidural space, removal of catheter was planned and while withdrawing the catheter with gentle traction, it sheared off at 5cm mark. A neurosurgical consultation was taken and we tried to locate the retained epidural catheter with the help of C - arm digital X ray in the operation theater, but severed catheter in the back could not be visualized. Plan for combined spinal epidural lumbar anaesthesia was abandoned. Here the dilemma begins, whether to proceed with proposed surgery under general anaesthesia leaving sheared catheter as such or post pone the surgery and do the needful for locating and removing the retained catheter. As the patient was asymptomatic, after detailed discussion with the operating surgeon, surgery was performed under general anesthesia which was uneventful. On second post-operative day, patient was taken to radiology department for locating the retained broken fragment with the help of ultrasound and computed tomography (CT). But we couldn’t locate the broken segment. The patient was followed up for the development of any complication such as backache, infection on the injection site, or neurological sequelae. She remained stable till the day of discharge. The advice was also sought from the neurosurgeon, and after a thorough discussion with the patient, it was decided to leave the broken catheter tip as such. Event was documented and patient was given assurance about the inert nature of the catheter fragment. She was educated about warning signs like redness or pain at injection site in back, any radiating pain or weakness in lower limbs and instructed to revert back as soon as possible.
Discussion:
The benefits of the epidural block have increased by several folds after the introduction of epidural catheters, permitting extension of neuraxial blockade for several hours including the postoperative period. However, like any other anesthetic technique, it is also not free of risks, of which fractured or sheared epidural catheter is an uncommon and a troublesome occurrence.
Epidural catheters are radio opaque, though broken retained fragment may not be visible radiologically because of more radio-dense surrounding structures.[2] MRI can detect spinal stenosis secondary to epidural fibrosis or scar formation. CT scan is more sensitive than plain radiography for detecting small retained fragment. In our case CT followed by USG was done to locate the severed catheter on 2nd post-operative day. Severed catheter could not be visualized.
In cases with epidural catheter breakage, the currently accepted consensus on treatment is that surgical removal is not necessary if the broken fragment is sterile and inert, and if the patient has no neurological complaints[3]. A study on cats demonstrated that broken fragments were surrounded by fibrous tissue within 3 weeks and remained harmlessly in the epidural area[4]. The present patient, who has been under follow-up for one year, remained asymptomatic with no neurological complaints. In symptomatic patients, immediate neurosurgical consultation for early surgical intervention should be considered. Although many studies have recommended imaging, we think that decision making and monitoring can be performed based on the individual patient’s clinical picture because most broken fragments cannot be visualized and surgery can only be performed in a limited number of cases such as leaking CSF through the catheter whose tip is either placed or migrated to intrathecal space[5] or either the patient develops infection or radicular pain due to nerve entrapment[6] or when the broken end of the catheter is emerging out of the skin, acting as a portal of entry for infection. A rare complication of the development of spinal stenosis due to the formation of reactive scar tissue around the broken catheter piece in the epidural space. One case report recently mentioned the development of delayed onset subdural hematoma following epidural catheter breakage after 18 years of its placement.[7] Thus after taking expert opinion from neurosurgeon, reviewing literatures and informing the patient, we decided to monitor the patient as patient was asymptomatic and the broken fragment was very small.
Common causes of fractured epidural catheter are: (1) When excessive length of the catheter has been inserted. (2) When excessive force is used to advance the catheter against resistance. (3) When Tuohy needle is advanced over the catheter. (4) When the catheter gets entrapped between the tip of needle and a bony surface. (5) When excessive force is applied to remove a knotted, kinked, or entrapped catheter. (6) Weak catheter due to manufacturing defect.
Recommendations to prevent epidural catheter fracture: (1) Excessive insertion should be avoided to prevent coiling, knotting, and entrapment of catheter.[8],[9] (2) On encountering resistance, both the needle and catheter should be removed as a single unit. (3) Catheter should be checked for manufacturing defects and sharp bevel tip should be ruled out. (4) A flexed lateral decubitus position is reported to be more effective than the sitting position, with withdrawal forces being as much as 2.5 times greater in the sitting position.[10] (5) Epidural catheter saline injection with simultaneous slow but firm traction can be tried in difficult catheter removal cases.[11] (5) Removal of the catheter should be done by the anesthesiologist or trained personnel.[9] (6)In difficult removal situation, one can choose between incision under local anesthesia with sedation and general anesthesia with muscle relaxants.
Quality of catheter is equally important to prevent such incidences. An ideal catheter should be radiopaque, flexible and disposable and have stretching capacity.
Conclusion:
It is clear that asymptomatic patients with broken epidural catheter should be counselled for warning signs and closely followed up for any delayed complication. Various case reports have shown that imaging techniques are not very much helpful in localizing retained catheter. Wherein broken fragment cannot be detected even in surgery. Surgical management is required only for the symptomatic patients. As for the ethical aspect, we believe that event should be documented and patients and their relatives should be provided the necessary information.
References
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