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CASE REPORT
Year : 2007  |  Volume : 51  |  Issue : 5  |  Page : 434 Table of Contents     

Epidural Catheter Breakage: A Dilemma


1 MD, Consultant, Department of Anaesthesiology, Pain & Perioperative Medicine, Sir Ganga Ram Hospital, Sir Ganga Ram Hospital Marg, New Delhi - 110060, India
2 MD, Senior Consultant, Department of Anaesthesiology, Pain & Perioperative Medicine, Sir Ganga Ram Hospital, Sir Ganga Ram Hospital Marg, New Delhi - 110060, India
3 DA, DNB, Senior Resident, Department of Anaesthesiology, Pain & Perioperative Medicine, Sir Ganga Ram Hospital, Sir Ganga Ram Hospital Marg, New Delhi - 110060, India
4 MD, FFARCS, PGDHHM, Senior Consultant, Chairperson, Department of Anaesthesiology, Pain & Perioperative Medicine, Sir Ganga Ram Hospital, Sir Ganga Ram Hospital Marg, New Delhi - 110060, India

Date of Acceptance30-Aug-2007
Date of Web Publication20-Mar-2010

Correspondence Address:
Deepanjali Pant
Department of Anaesthesiology, Pain & Perioperative Medicine, Sir Ganga Ram Hospital, Sir Ganga Ram Hospital Marg, New Delhi - 110060.
India
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Placement of an epidural catheter in epidural space is a routine practice for providing anaesthesia/analgesia in a myriad of surgical procedures and various painful conditions. Breakage of an epidural catheter, though rare, is a well-known complication. We present a case report of such an event and a comprehensive review of do's and don'ts in this setting.

Keywords: Epidural catheter, Breakage, Management.


How to cite this article:
Pant D, Jain P, Kanthed P, Sood J. Epidural Catheter Breakage: A Dilemma. Indian J Anaesth 2007;51:434

How to cite this URL:
Pant D, Jain P, Kanthed P, Sood J. Epidural Catheter Breakage: A Dilemma. Indian J Anaesth [serial online] 2007 [cited 2014 Aug 31];51:434. Available from: http://www.ijaweb.org/text.asp?2007/51/5/434/61178


   Introduction Top


A broken spinal or epidural catheter, although an uncommon occurrence, remains an area of utmost di­lemma to the practising anaesthesiologist. While the in­sertion of a spinal or epidural catheter is usually safe, they have been known to break during removal, leaving a segment lodged in patient's back. [1] Since surgical re­moval of a broken catheter is not recommended and the severed nonbiodegradable catheter is situated in an ana­tomical region which does not permit it to be naturally extruded, it is left in the patient permanently. [2] The dis­comfort to the patient and the formidable complication that may rarely result from such a mishap could greatly deter surgeons, anaesthesiologists and patients from this most useful anaesthetic technique. .


   Case report Top


A 70 -yr - old, 65 kg male, presented with history of road traffic accident leading to multiple rib fractures on right side. He was a known case of COPD, on inter­mittent bronchodilator therapy. Due to severe pain re­lated to rib fracture, the patient was unable to cough out secretions effectively. He was referred to acute pain services for pain relief.

A thoracic epidural analgesia was planned and us­ing the loss-of-resistance technique with air, an 18G ra­dio opaque epidural catheter [Perifix® 401 G18x3 1 / 4"(B/ Braun)] was inserted through an 18G Tuohy needle into the epidural space at T 8 -T 9 interspace in left lateral posi­tion. The epidural space was encountered at 5 cm from skin and catheter was advanced cephalad upto 15 cm at hub of the needle. Resistance was encountered while injecting the test dose and therefore it was decided to relocate the epidural space. While the catheter was be­ing removed with gentle traction along with Tuohy needle, it sheared off at 6 cm mark. [Figure 1]

A new epidural catheter was placed at the T 11 -T 12 interspace and fixed at 9 cm mark (skin to epidural dis­tance = 5 cm). Patient controlled epidural analgesia (PCEA) was initiated with a combination of 0.0625% bupivacaine hydrochloride and fentanyl citrate (5pg.ml­1 ). The patient had adequate pain relief and chest condi­tion improved satisfactorily. PCEA was used for 7 days and the epidural catheter was removed uneventfully. Subsequently the patient was discharged without any neurological sequelae.

After informing the surgeon and the patient, an MRI and CT scan were done. Sagittal 3-mm (with 1­mm gap) and axial 5-mm (with 1.5-mm gap) T 1­weighted spin-echo (TR 500 ms/TE16 ms/ 2 excitation) and proton density and T 2 - weighted (TR 2600 ms/TE 16,96 ms/2 excitation) fast spin-echo images were ob­tained in a 1.5T MRI scanner (General electric signal) (matrix 256x256, field of view 20 cm axial, 28 cm sagit­tal). Axial and sagittal T 1 -weighted images after IV gadolinium DTPA were obtained. CT scan (4-mm im­ages obtained at 3-mm interval) with sagittal and coro­nal reconstruction was done. But the severed epidural catheter was not visualized.

The patient was counselled that this event had occurred and was advised to report in case of any adverse symptoms.


   Discussion Top


Not many cases have been reported and there is always a dilemma in the mind of all - doctor to patient, regarding the sequence of leaving the catheter fragment in situ. So we thought of briefly reviewing the literature about various possible causes, ways to prevent, diag­nose and manage such a case.


   Causes of severed epidural catheter Top


  1. Application of undue force in removing a catheter trapped between vertebral spinous processes or in ligamentum flavumor knotted, kinked or curled cath­eter in epidural space causes the catheter to stretch or tear. [3],[4]
  2. Shearing of catheter by needle when attempts are made to withdraw the catheter through the Tuohy needle.
  3. Nicking of a catheter by a barb on the bevel of the needle.
  4. Shredding of catheter if the needle is advanced over the catheter after the catheter has been placed.
  5. Weakness of the catheter by imperfect manufac­turing.
  6. Damage to a catheter occurring after placement i.e. fraying by pinching between two vertebral pro­cesses. [5],[6]
  7. The proposed mechanism for catheter that were severed at time of insertion is to break or severely damage an epidural catheter by heavy contact be­tween tip of the epidural needle and a bony surface, if a length of the catheter was protruding from the tip. [7]
  8. Catheter damage is often related to excessive in­sertion into the epidural space. [8],[9]



   Prevention of catheter breakage - recommenda­tions Top


  1. Lateral decubitus position when removing an epi­dural catheter as this results in least force of ex­traction. [10]
  2. The force required to remove a catheter should be minimal. If resistance is encountered, a number of simple maneuvers may help to enable removal of catheter without stretching or tearing. These include (stepwise):-

    a. Maximal flexion of back in lateral decubitus po­sition

    b. Rotation of spine

    c. Returning the patient to the position used at time of insertion e.g. sitting position with legs ex­tended or kneeling position with hands down and back flexed

    d. Allowing tissues to soften for 15- 30 minutes before reattempting [11]

    e. Filling the catheter with a rapid injection of sa­line to increase the turgor of the catheter and to lubricate it.

    f. Complete relaxation with GA with muscle re­laxation

    g. Surgical removal

  3. The needle should be checked for barbs on bevel and the catheter for manufacturing defects before insertion.
  4. No more than 4-5 cm of catheter should be ad­vanced into the epidural space to reduce risk of kink­ing /curling /knotting. [8],[12],[13]
  5. Catheter should never be withdrawn through the metal needle.
  6. Catheters of high breaking strain (tensile strength) and of a sufficient diameter (16/18G) should be ob­tained from a reputable, reliable manufacturer.
In our case, there was no obvious cause for break­age. Most probably it was kinked or curled, as there was resistance during drug injection.


   Diagnosis Top


Attempts to locate the torn catheter ultrasonically are usually futile but xeroradiography, CT scanning or MRI may prove more fruitful.

Radio opaque epidural catheters are easier to lo­cate radiologically than non-radio opaque ones, but para­doxically, they have a lower tensile strength than stan­dard clear catheters. In fact, a radioopaque fragment may be impossible to locate radiologically because the surrounding structures are radio-dense.

MRI scanning is a non-invasive means of diagnos­ing the complication of spinal stenosis secondary to epi­dural fibrosis/scar formation and assessing the extent of spinal stenosis.

However, CT scanning through level of interest is more sensitive than MRI in detecting the high attenuation catheter fragment within the epidural space and is more sensitive than plain radiography, especially for small retained fragments.

In our case CT / MRI did not help to locate the fragment - since they are helpful once there is a reac­tive mass around the catheter fragment.


   Management Top


Sequestered temporary epidural catheter pieces are generally considered to be inert and should not produce a foreign body reaction. Experiments with cats have shown that a broken catheter becomes walled off by fibrous tis­sue after about3 weeks -remaining innocuous within the epidural space. [13] Foreign body in epidural space is not likely to migrate (although this is not impossible).

However, Staats et al reported the formation of a reactive epidural mass (1.5cm) around the catheter frag­ment resulting in lumbar spinal stenosis, patient being as­ymptomatic until 18 months of the incident and got re­lieved with removal of catheter and reactive scar tissue. [14]

In contrast, the continued presence of indwelling catheter has resulted in complications. Chronic, implanted intrathecal infusion catheters have been associated with granuloma formation resulting in spinal cord compres­sion. The changes may occur, rather quickly, as noted by Durant and Yatish, who reported that catheters can be walled off by tissue reaction after 72 hours. [15] This local reaction was reported by Coombs et al, who found "cocoon" formation with dural thickening around im­planted catheters in post-mortem examination. [16]

Therefore, in most cases the current standard of care application to the retained segments of a tempo­rary epidural catheter is to leave them alone unless symp­tomatic because surgical removal can produce more harm than good. [2] However, there are 3 situations where a policy of non-interference or reassurance does not apply.

  1. Where infection or symptoms supervene, a careful history and physical examination should help deter­mine the spinal level involved.
  2. If the spinal catheter fragment is sitting partially intrathecally and is acting as a wick which allows persistent CSF leakage. [12] If a continuous spinal micro-catheter becomes separated within the in­trathecal space, appropriate imaging, a neurosurgi­cal consultation and aggressive surgical exploration to retrieve the broken piece are warranted, even in the asymptomatic patient. [17]
  3. If the proximal end of the segment is located at or just beneath the skin such that it can be retrieved simple through a superficial incision made under lo­cal anaesthesia. The broken distal piece is grasped with a curved haemostat and drawn out by firm, gentle traction. [6] Surgical removal is mandatory in such a situation as bacteria can readily track along the catheter remnant.
On rare occasions, surgical exploration may be needed to remove lost catheter fragments and associ­ated reactive scar tissue and relieve spinal stenosis. Successful localization of catheter fragment by medi­cal imaging is no guarantee that task of finding the miss­ing segment at subsequent surgery will be made any easier.

If pain is caused by traction on catheter, the anaesthesiologist should suspect that a loop may have become curled around a nerve root. So removal of a catheter under anaesthesia may not help to alert the medical team in such a case. Given the possibility that avulsion might occur, it would probably be wise to ex­tract the catheter under direct vision by open surgical laminectomy. [18] Sidhu et al described a parturient having epidural catheter coiled around L 2 -L 3 nerve root, caus­ing severe pain and paresthesia on traction, but produc­ing no sensory or motor defect. Since the patient re­fused a surgical procedure, catheter was removed with­out sequelae by gentle traction in various positions. [19]

Any kind of trauma, like practice of securing the catheter by a suture at skin level, may cause microlesions and deteriorates the energy adsorbing capacity of cath­eter considerably - therefore, it should be practiced only when absolutely indicated. [20]

Our patient has not reported any adverse symp­toms so far till the writing of this article - a time period of roughly two years.


   Newer inventions Top


More recently, it has been proposed to provide an improved epidural catheter which maintains its structural integrity for intraoperative and postoperative period and eliminates the necessity for an additional surgical proce­dure or any outside intervention in order to remove a portion of the catheter should breakage occur. It exhibits good handling properties, has adequate tensile strength, is sterilizable and can be uniformly manufactured using conventional techniques. It is made up of biodegradable material (synthetic polymers of absorbable material) which dissolves with time upon contact with moisture found in body fluids with no undesirable degradation sub­stance released into body. [21] Since it is adversely affected by moisture it is preferably packaged in a substantially moisture-free environment prior to use and in sealed sterile packages.

In general, the material should generally maintain its original integrity for at least 3 days and should be com­pletely absorbed in living tissue in a period of time from approximately 20 to 120 days. The degradation time of the biodegradable material can be selectively altered by adjusting the molecular weight or chemical make-up of the synthetic polymers or through irradiation with gamma rays that simultaneously sterilizes the catheter without any significant loss of other desirable properties.

In conclusion, inspite of the best intentions and ex­ercise of utmost care it can still result in tearing of an epidural catheter. But fortunately in only a small propor­tion of these cases, it is prudent to attempt to remove the offending retained portion of the catheter.

The usual guidelines for insertion and removal of catheter should be strictly followed on a routine basis to prevent the occurrence.

The presence of a retained epidural catheter fragment should be documented and communicated to the patient, surgeon and primary care physician because the development of symptoms related to the catheter may occur months or years later and the patient should be reviewed periodically to ensure that there is no discom­fort, infection or radiculopathy. If symptoms develop, spine imaging to find out the level of involvement and surgery is advocated.

 
   References Top

1.Tio T, Macmurdo S, McKenzie R. Mishap with an epidural catheter. Anesthesiology 1979; 50:260-62.  Back to cited text no. 1      
2.DeVera H, Ries M. Complication of continuous spinal microcatheter: should we seek their removal if sheared? Anes­thesiology 1991; 74:794.  Back to cited text no. 2      
3.Gough JD,Johnston KR,Harmer M. Kinking of epidural cath­eters. Anaesthesia 1989; 40:1060.  Back to cited text no. 3      
4.Jongleux EF,Miller R,Freeman A. An entrapped epidural catheter in a postpartum patient.Reg Anesth Pain Med 1998;23:615-17.  Back to cited text no. 4      
5.Simpson P. Defective epidural cannulae. Anaesthesia 1981; 36:72.  Back to cited text no. 5      
6.DeArmendi A,Ryan J,Chang H, et al. Retained caudal catheter in a paediatric patient. Paed Anaes 1992; 2:325-27.  Back to cited text no. 6      
7.Collier C. Epidural catheter breakage: a possible mechanism. Int J Obstet Anesth 2000; 9: 87 -93.  Back to cited text no. 7      
8.Dawkins M. An analysis of the complications of extradural and caudal block. Anaesthesia 1969; 24:554-63.  Back to cited text no. 8      
9.Dounas M,Peillon P, Lebonhomme JJ, et al .Difficulties in the removal and rupture of a peridural catheter.Ann Fr Anesth Reanim 2002;21:600-2.  Back to cited text no. 9      
10.Morris GN,Warren BB,Hanson EW,et al.Influence of patient position on withdrawal forces during removal of lumbar extra­dural catheters. Anesthesiology 1997; 86:778-84.  Back to cited text no. 10      
11.Demiraran Y, Yucel I, Erdogmus B. Subcutaneous effusion re­sulting from an epidural catheter fragment. Br J Anaesth 2006; 96:508-9.  Back to cited text no. 11      
12.Pasquariello C,Betz R. A case for the removal of the retained intrathecal catheter. Anesth Analg 1991;72:562.  Back to cited text no. 12      
13.Bromage PR.Epidural Analgesia. Philadelphia,WB Saunders. 1978 pp 664-66.  Back to cited text no. 13      
14.Staats PS,Stinson MS,LeeR.Lumbar stenosis complicating re­tained epidural catheter tip.Anesthesiology 1995;83:1115-18.  Back to cited text no. 14      
15.Durant PA,Yatish JL. Epidural injection of bupivacaine, mor­phine, fentanyl, lofentanil and DADL in chronically implanted rats: a pharmacologic and pathologic study. Anesthesiology 1986; 64:43-53.  Back to cited text no. 15      
16.Coombs DW,Franklin JD,Meier FA,et al.Neuropathologic le­sions and CSF morphine during chronic continuous intraspinal morphine infusion: a clinical & post mortem study.Pain 1985;22:337-51.  Back to cited text no. 16      
17.Ugboma S, Au - Truong X, Kranzler LI, et al. The breaking of an intrathecally placed epidural catheter during extraction. Anesth Analg 2002; 95: 1087 - 9.  Back to cited text no. 17      
18.Bromage PR.Epidural Analgesia.Philadelphia.WB Saunders 1978,pp240.  Back to cited text no. 18      
19.Sidhu MS,Asrani RV,Bassell GM. An unusual complication of extradural catheterization in obstetric anaesthesia. Br JAnaesth 1983; 55:473-75.  Back to cited text no. 19      
20.Schummer W, Schummer C. Another causeof epidural catheter breakage ? Anesth Analg 2002;94:233.  Back to cited text no. 20      
21.http://www.freepatentsonline .com/5129889.html. (US Patent no 5129889).  Back to cited text no. 21      


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