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Difficult Removal of an Epidural Catheter in the Anterior Epidural Space
Acta Anaesthesiol Taiwan 2010;48(1):49−52
C ASE R EPO RT
Difficult Removal of an Epidural Catheter in the Anterior Epidural Space Jia-Lin Chen1, Chen-Hwan Cherng1, Shun-Ming Chan1, Chia-Shiang Lin2, Chih-Shung Wong1, Chun-Jung Juan3, Chun-Chang Yeh1* 1
Department of Anesthesiology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, R.O.C. 2 Department of Anesthesiology, Mackay Memorial Hospital, Mackay Medicine, Nursing and Management College, Taipei, Taiwan, R.O.C. 3 Department of Radiology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, R.O.C.
Received: Aug 20, 2009 Revised: Jan 14, 2010 Accepted: Jan 20, 2010 KEY WORDS: analgesia, epidural; catheters, indwelling; contrast media; epidural space: anterior; fluoroscopy; prone position
When administering postoperative acute pain services, particularly regarding patientcontrolled epidural analgesia, difficulties may occasionally be encountered during removal of the epidural catheter. In this report, we present an instance of difficult removal of epidural catheter in a female patient undergoing open reduction and internal fixation of the femoral neck with patient-controlled epidural analgesia as the means of postoperative pain control. The patient had satisfactory analgesia for 3 days; however, during the removal of the epidural catheter, difficulties were encountered and epidurogram revealed that the epidural catheter had become anchored in the anterior epidural space without kinking or knotting. Subsequently, the patient was requested to lie prone on the surgical table with a pillow placed beneath her lower abdomen and catheter removal was tried again. Fortunately, the epidural catheter was removed easily without the need for a guided stylet. We believe that the cause of the difficult removal of the epidural catheter in this case might have resulted from an unusual and unwanted deeper anchorage of the catheter along the anterior epidural space during placement. We also include some discussion on the management of problematic removal.
1. Introduction Patient-controlled epidural analgesia (PCEA) can provide excellent pain relief after truncal surgery. However, difficulty in removing the epidural catheter may occasionally arise. Management of epidural catheter extraction has been reported,1 but there are no clear management guidelines.
A common manipulation is to request the patient to assume the same position as when the catheter was inserted.2 A continuous and steady force is recommended when the catheter is being removed. If this does not work, we must consider the possible reasons for why the catheter cannot be removed, such as knotting and kinking. Knotting is the most common cause of difficult removal,
*Corresponding author. Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan, R.O.C. E-mail: [email protected] ©2010 Taiwan Society of Anesthesiologists
50
J.L. Chen et al
and if present, its whereabouts may be determined by radiological imaging.3 To our knowledge, this report is the first to describe difficult removal of epidural catheter due to incidental placement of the catheter in the anterior epidural space. After several unsuccessful attempts to remove the catheter, fluoroscopy was employed to determine the cause. Before resorting to a more invasive method, we tried again to retrieve the catheter with the patient in the prone position. Fortunately, the catheter was successfully removed on this attempt with no adverse sequelae.
2. Case Report A 32-year-old woman (weight, 72 kg; height, 156 cm) with no history of systemic disease was admitted to our hospital for orthopedic surgery due to right femoral neck fracture. To provide adequate postoperative analgesia for facilitating postoperative recovery, an epidural catheter was inserted for postoperative pain control before spinal anesthesia. An 18-gauge Tuohy needle was inserted via the paramedian approach at L3−L4 vertebral interspace and the epidural space was identified by using the lossof-resistance to air technique. An 18-gauge Portex® epidural catheter (Smiths Medical International Ltd, Kent, UK) was then inserted and advanced 7.0 cm into the epidural space with the 14-cm mark at the aperture of the skin without any difficulty. An epidural test dose of 3 mL of 2% lidocaine with 1:200,000 epinephrine indicated positively that the epidural catheter was neither intrathecally nor intravascularly placed. The patient tolerated the procedure well and had a smooth postoperative recovery with satisfactory pain control. Three days after the operation, when it was time for the catheter to be removed, the anesthesia resident encountered difficulty in removing the catheter and had two failed attempts. The attending anesthesiologist who came to help the resident also encountered difficulty, even with the patient assuming either the sitting position with flexed back or the lateral decubitus flexion position. After explaining the situation to the patient and her family, and discussing the options with them, the patient was sent to the operating room for an epidurogram in order to discover the cause of difficult removal. The patient lay on the surgical table in the prone position with a pillow placed beneath her lower abdomen. The epidurogram showed that the catheter was partially located in the anterior epidural space (Figure 1), and had not knotted, kinked or broken (Figures 1−3). The path of the epidural catheter, as traced, started from the left border of the L3 superior endplate of the vertebral body, then
Figure 1 Epidurogram, lateral view, shows catheter placement in the anterior epidural space.
ran close to the inferior border of the pedicle, and finally entered the anterior epidural space probably through the left L2 foraminal space (Figure 1). We made another attempt to remove the catheter, and fortunately, the catheter was easily extracted on this last attempt. The catheter was largely intact, but a deformed section was noted around the entrapped point of the catheter. The patient was discharged 2 days later without any neurological sequelae.
3. Discussion Difficult removal of epidural catheters occasionally occurs, and several maneuvers have been recommended:4−7 (1) use slow, continuous and steady pressure on the catheter to avoid catheter breakage; (2) reapply force and traction several hours later; (3) have the patient adopt the same position as when the catheter was inserted; (4) have the patient adopt the lateral decubitus position (as greater force is required to remove the epidural catheter in the flexed sitting position than in the lateral position); (5) attempt removal after injection of normal saline through the catheter, which may also assist in determining whether the catheter is knotted. There are several causes of problematic epidural catheter removal, such as catheter breakage or knotting.8,9 In this instance, the patient experienced satisfactory postoperative analgesia for 3 days. To evaluate the difficult removal of the catheter, we administered normal saline through the catheter to exclude the possibility of catheter knotting, because the catheter had been inserted more than 5 cm into the epidural space.10 Catheter knotting is a typical but rare complication of epidural
Difficult removal of an epidural catheter A
51
B
C
Figure 2 (A) Preoperative X-ray shows no significant findings except for lumbar sacralization. Epidurogram shows no knotting or shearing: (B) anteroposterior view; (C) potential pathway of the epidural catheter (represented by the red dotted line).
Figure 3 The removed epidural catheter shows no knotting or breaking, but a deformed section is noted at the entrapped point of the catheter (arrow).
anesthesia/analgesia, with an approximate incidence of 0.0015%.11 The catheter being threaded into the epidural space too deeply is a risk factor for this complication.12 In order to identify other possible etiologies of entrapment and location of epidural catheter, fluoroscopy may be required.13 The patient lies on the surgical table in the prone position on a pillow for taking the epidurogram. In our patient, after injecting 3 mL of contrast dye (Isovist-300), the epidurogram confirmed that the catheter was inserted from the L3/4 interspace and had entered the anterior epidural space without knotting, shearing or other abnormal deformities. Then we tried to remove the catheter one last time; surprisingly, the catheter was successfully removed. In addition to the maneuvers described above, the prone position was recommended in one article.14 We believe that the catheter being anchored in the anterior epidural space was the reason for its difficult removal in our patient. There is no report in the literature
that explores the incidence of catheter anchorage in the anterior epidural space after it has been placed via the paramedian approach, and its potential difficult removal. The primary cause of the catheter ending up in the anterior epidural space may be related to the initial needle insertion spot, which was 3 cm lower from the L3/4 vertebrae interspace, the needle inserting angle, which is more acute in the paramedian approach, and the direction of needle insertion. From the anatomic perspective, the anterior epidural space is narrower than the posterior epidural space. The occurrence of directly placing an epidural catheter into the anterior space is very rare. Additional reasons for difficult catheter removal in our patient include the deeper placement of the catheter and the fact that the patient was obese (body mass index, 29.6 kg/m2).15 In this case, we were able to remove the epidural catheter only when the patient was in the prone position with a pillow placed beneath the lower abdomen. The possible reason for successful extraction in this obese patient is that as the pillow pressed against the abdomen, the back took on a more flexed angle. The contrast medium that was injected might also have acted as a lubricant and reshaped the catheter for easier removal. In summary, gentle traction of the catheter with a constant force and with the patient lying in the prone position on a pillow is another feasible strategy that is worth trying when difficulty in epidural catheter removal is encountered. Such a modality can ease muscle relaxation and can facilitate catheter removal.
References 1.
Mitra R, Fleischmann K. Management of the sheared epidural catheter: is surgical extraction really necessary? J Clin Anesth 2007;19:310−4.
52 2.
3.
4. 5.
6. 7. 8.
J.L. Chen et al Morris GN, Warren BB, Hanson EW, Mazzeo FJ, DiBenedetto DJ. Influence of patient position on withdrawal forces during removal of lumbar extradural catheters. Br J Anaesth 1996;77:419−20. Dam-Hieu P, Rodriguez V, De Cazes Y, Quinio B. Computed tomography images of entrapped epidural catheter. Reg Anesth Pain Med 2002;27:517−9. Gozal D, Gozal Y, Beilin B. Removal of knotted epidural catheters. Reg Anesth 1996;21:71−3. Hopf B, Leischik M. More on problems with removing the arrow FlexTip epidural catheter: smooth in-hardly out? Anesthesiology 2000;93:1362. Boey SK, Carrie LE. Withdrawal forces during removal of lumbar extradural catheters. Br J Anaesth 1994;73:833−5. Day C. Difficult removal of an epidural catheter. Anaesthesia 1993;48:448. Ben-David B, Rawa R. Complications of neuraxial blockade. Anesthesiol Clin N Am 2002;20:669−93.
9. 10. 11.
12.
13. 14.
15.
Ben-David B. Complications of regional anesthesia: an overview. Anesthesiol Clin N Am 2002;20:665−7. Fragneto RY. The broken epidural catheter: an anesthesiologist’s dilemma. J Clin Anesth 2007;19:243−4. Brichant JF, Bonhomme V, Hans P. On knots in epidural catheters: a case report and a review of the literature. Int J Obstet Anesth 2006;15:159−62. Renehan EM, Peterson RA, Penning JP, Rosaeg OP, Chow D. Visualization of a looped and knotted epidural catheter with a guidewire. Can J Anaesth 2000;47:329−33. Pierre HL, Block BM, Wu CL. Difficult removal of a wirereinforced epidural catheter. J Clin Anesth 2003;15:140−1. Jongleux EF, Miller R, Freeman A. An entrapped epidural catheter in a postpartum patient. Reg Anesth Pain Med 1998;23:615−7. Hamilton CL, Riley ET, Cohen SE. Changes in the position of epidural catheters associated with patient movement. Anesthesiology 1997;86:778−84; discussion 29A.
C ASE R EPO RT
Difficult Removal of an Epidural Catheter in the Anterior Epidural Space Jia-Lin Chen1, Chen-Hwan Cherng1, Shun-Ming Chan1, Chia-Shiang Lin2, Chih-Shung Wong1, Chun-Jung Juan3, Chun-Chang Yeh1* 1
Department of Anesthesiology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, R.O.C. 2 Department of Anesthesiology, Mackay Memorial Hospital, Mackay Medicine, Nursing and Management College, Taipei, Taiwan, R.O.C. 3 Department of Radiology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, R.O.C.
Received: Aug 20, 2009 Revised: Jan 14, 2010 Accepted: Jan 20, 2010 KEY WORDS: analgesia, epidural; catheters, indwelling; contrast media; epidural space: anterior; fluoroscopy; prone position
When administering postoperative acute pain services, particularly regarding patientcontrolled epidural analgesia, difficulties may occasionally be encountered during removal of the epidural catheter. In this report, we present an instance of difficult removal of epidural catheter in a female patient undergoing open reduction and internal fixation of the femoral neck with patient-controlled epidural analgesia as the means of postoperative pain control. The patient had satisfactory analgesia for 3 days; however, during the removal of the epidural catheter, difficulties were encountered and epidurogram revealed that the epidural catheter had become anchored in the anterior epidural space without kinking or knotting. Subsequently, the patient was requested to lie prone on the surgical table with a pillow placed beneath her lower abdomen and catheter removal was tried again. Fortunately, the epidural catheter was removed easily without the need for a guided stylet. We believe that the cause of the difficult removal of the epidural catheter in this case might have resulted from an unusual and unwanted deeper anchorage of the catheter along the anterior epidural space during placement. We also include some discussion on the management of problematic removal.
1. Introduction Patient-controlled epidural analgesia (PCEA) can provide excellent pain relief after truncal surgery. However, difficulty in removing the epidural catheter may occasionally arise. Management of epidural catheter extraction has been reported,1 but there are no clear management guidelines.
A common manipulation is to request the patient to assume the same position as when the catheter was inserted.2 A continuous and steady force is recommended when the catheter is being removed. If this does not work, we must consider the possible reasons for why the catheter cannot be removed, such as knotting and kinking. Knotting is the most common cause of difficult removal,
*Corresponding author. Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan, R.O.C. E-mail: [email protected] ©2010 Taiwan Society of Anesthesiologists
50
J.L. Chen et al
and if present, its whereabouts may be determined by radiological imaging.3 To our knowledge, this report is the first to describe difficult removal of epidural catheter due to incidental placement of the catheter in the anterior epidural space. After several unsuccessful attempts to remove the catheter, fluoroscopy was employed to determine the cause. Before resorting to a more invasive method, we tried again to retrieve the catheter with the patient in the prone position. Fortunately, the catheter was successfully removed on this attempt with no adverse sequelae.
2. Case Report A 32-year-old woman (weight, 72 kg; height, 156 cm) with no history of systemic disease was admitted to our hospital for orthopedic surgery due to right femoral neck fracture. To provide adequate postoperative analgesia for facilitating postoperative recovery, an epidural catheter was inserted for postoperative pain control before spinal anesthesia. An 18-gauge Tuohy needle was inserted via the paramedian approach at L3−L4 vertebral interspace and the epidural space was identified by using the lossof-resistance to air technique. An 18-gauge Portex® epidural catheter (Smiths Medical International Ltd, Kent, UK) was then inserted and advanced 7.0 cm into the epidural space with the 14-cm mark at the aperture of the skin without any difficulty. An epidural test dose of 3 mL of 2% lidocaine with 1:200,000 epinephrine indicated positively that the epidural catheter was neither intrathecally nor intravascularly placed. The patient tolerated the procedure well and had a smooth postoperative recovery with satisfactory pain control. Three days after the operation, when it was time for the catheter to be removed, the anesthesia resident encountered difficulty in removing the catheter and had two failed attempts. The attending anesthesiologist who came to help the resident also encountered difficulty, even with the patient assuming either the sitting position with flexed back or the lateral decubitus flexion position. After explaining the situation to the patient and her family, and discussing the options with them, the patient was sent to the operating room for an epidurogram in order to discover the cause of difficult removal. The patient lay on the surgical table in the prone position with a pillow placed beneath her lower abdomen. The epidurogram showed that the catheter was partially located in the anterior epidural space (Figure 1), and had not knotted, kinked or broken (Figures 1−3). The path of the epidural catheter, as traced, started from the left border of the L3 superior endplate of the vertebral body, then
Figure 1 Epidurogram, lateral view, shows catheter placement in the anterior epidural space.
ran close to the inferior border of the pedicle, and finally entered the anterior epidural space probably through the left L2 foraminal space (Figure 1). We made another attempt to remove the catheter, and fortunately, the catheter was easily extracted on this last attempt. The catheter was largely intact, but a deformed section was noted around the entrapped point of the catheter. The patient was discharged 2 days later without any neurological sequelae.
3. Discussion Difficult removal of epidural catheters occasionally occurs, and several maneuvers have been recommended:4−7 (1) use slow, continuous and steady pressure on the catheter to avoid catheter breakage; (2) reapply force and traction several hours later; (3) have the patient adopt the same position as when the catheter was inserted; (4) have the patient adopt the lateral decubitus position (as greater force is required to remove the epidural catheter in the flexed sitting position than in the lateral position); (5) attempt removal after injection of normal saline through the catheter, which may also assist in determining whether the catheter is knotted. There are several causes of problematic epidural catheter removal, such as catheter breakage or knotting.8,9 In this instance, the patient experienced satisfactory postoperative analgesia for 3 days. To evaluate the difficult removal of the catheter, we administered normal saline through the catheter to exclude the possibility of catheter knotting, because the catheter had been inserted more than 5 cm into the epidural space.10 Catheter knotting is a typical but rare complication of epidural
Difficult removal of an epidural catheter A
51
B
C
Figure 2 (A) Preoperative X-ray shows no significant findings except for lumbar sacralization. Epidurogram shows no knotting or shearing: (B) anteroposterior view; (C) potential pathway of the epidural catheter (represented by the red dotted line).
Figure 3 The removed epidural catheter shows no knotting or breaking, but a deformed section is noted at the entrapped point of the catheter (arrow).
anesthesia/analgesia, with an approximate incidence of 0.0015%.11 The catheter being threaded into the epidural space too deeply is a risk factor for this complication.12 In order to identify other possible etiologies of entrapment and location of epidural catheter, fluoroscopy may be required.13 The patient lies on the surgical table in the prone position on a pillow for taking the epidurogram. In our patient, after injecting 3 mL of contrast dye (Isovist-300), the epidurogram confirmed that the catheter was inserted from the L3/4 interspace and had entered the anterior epidural space without knotting, shearing or other abnormal deformities. Then we tried to remove the catheter one last time; surprisingly, the catheter was successfully removed. In addition to the maneuvers described above, the prone position was recommended in one article.14 We believe that the catheter being anchored in the anterior epidural space was the reason for its difficult removal in our patient. There is no report in the literature
that explores the incidence of catheter anchorage in the anterior epidural space after it has been placed via the paramedian approach, and its potential difficult removal. The primary cause of the catheter ending up in the anterior epidural space may be related to the initial needle insertion spot, which was 3 cm lower from the L3/4 vertebrae interspace, the needle inserting angle, which is more acute in the paramedian approach, and the direction of needle insertion. From the anatomic perspective, the anterior epidural space is narrower than the posterior epidural space. The occurrence of directly placing an epidural catheter into the anterior space is very rare. Additional reasons for difficult catheter removal in our patient include the deeper placement of the catheter and the fact that the patient was obese (body mass index, 29.6 kg/m2).15 In this case, we were able to remove the epidural catheter only when the patient was in the prone position with a pillow placed beneath the lower abdomen. The possible reason for successful extraction in this obese patient is that as the pillow pressed against the abdomen, the back took on a more flexed angle. The contrast medium that was injected might also have acted as a lubricant and reshaped the catheter for easier removal. In summary, gentle traction of the catheter with a constant force and with the patient lying in the prone position on a pillow is another feasible strategy that is worth trying when difficulty in epidural catheter removal is encountered. Such a modality can ease muscle relaxation and can facilitate catheter removal.
References 1.
Mitra R, Fleischmann K. Management of the sheared epidural catheter: is surgical extraction really necessary? J Clin Anesth 2007;19:310−4.
52 2.
3.
4. 5.
6. 7. 8.
J.L. Chen et al Morris GN, Warren BB, Hanson EW, Mazzeo FJ, DiBenedetto DJ. Influence of patient position on withdrawal forces during removal of lumbar extradural catheters. Br J Anaesth 1996;77:419−20. Dam-Hieu P, Rodriguez V, De Cazes Y, Quinio B. Computed tomography images of entrapped epidural catheter. Reg Anesth Pain Med 2002;27:517−9. Gozal D, Gozal Y, Beilin B. Removal of knotted epidural catheters. Reg Anesth 1996;21:71−3. Hopf B, Leischik M. More on problems with removing the arrow FlexTip epidural catheter: smooth in-hardly out? Anesthesiology 2000;93:1362. Boey SK, Carrie LE. Withdrawal forces during removal of lumbar extradural catheters. Br J Anaesth 1994;73:833−5. Day C. Difficult removal of an epidural catheter. Anaesthesia 1993;48:448. Ben-David B, Rawa R. Complications of neuraxial blockade. Anesthesiol Clin N Am 2002;20:669−93.
9. 10. 11.
12.
13. 14.
15.
Ben-David B. Complications of regional anesthesia: an overview. Anesthesiol Clin N Am 2002;20:665−7. Fragneto RY. The broken epidural catheter: an anesthesiologist’s dilemma. J Clin Anesth 2007;19:243−4. Brichant JF, Bonhomme V, Hans P. On knots in epidural catheters: a case report and a review of the literature. Int J Obstet Anesth 2006;15:159−62. Renehan EM, Peterson RA, Penning JP, Rosaeg OP, Chow D. Visualization of a looped and knotted epidural catheter with a guidewire. Can J Anaesth 2000;47:329−33. Pierre HL, Block BM, Wu CL. Difficult removal of a wirereinforced epidural catheter. J Clin Anesth 2003;15:140−1. Jongleux EF, Miller R, Freeman A. An entrapped epidural catheter in a postpartum patient. Reg Anesth Pain Med 1998;23:615−7. Hamilton CL, Riley ET, Cohen SE. Changes in the position of epidural catheters associated with patient movement. Anesthesiology 1997;86:778−84; discussion 29A.