- Email: [email protected]
Stiffen your catheter—not your resolve!
© Letters to the Editor Stiffen Your CathetermNot Your Resolve!
References
To the Editor:
l. Balance JH. Difficulty in the removal of an epidural catheter. Anaesthesia 1981,36:71-72. 2. Caldwell M, Dellaria S, Niedzwiecki C. Stretching of epidural nylon catheters on removal. Reg Anesth 1996;21:379-380. 3. Christie IW. Removal of lumbar extradural catheters. Br J Anaesth 1995;75:666. 4. Day C. Difficult removal of an epidural catheter. Anaesthesia 1993;48:448. 5. Shantha TR, Mani M. A simple method to retrieve irretrievable epidural catheters. Anesth Analg 1991;73:508-509. 6. Boey SK, Carrie LES. Withdrawal forces during removal of lumbar extradural catheters. Br J Anaesth 1994;73:833835.
Numerous reports have described epidural catheters that tenaciously resisted efforts at removal by traction alone. L2 Suggested solutions to the problem include such maneuvers as flexion of the spine, 3 injection of saline, 4 and retrieval through a second Tuohy needle? We wish to describe another technique that facilitated the removal of a stubborn epidural catheter. A 15-year-old gift presented with a retained 20-gauge midline lumbar epidural catheter (FlexTip Plus; Arrow International, Reading, PA), which had been inserted 3 days earlier for postoperative pain control. Repeated attempts at removal, with the patient in a flexed sitting position, produced a worrying degree of catheter stretch. She was brought to the operating room where the catheter was visualized using fluoroscopy. There was no evidence of knotting, but the distal 4 a n of the catheter was seen to be coiled within the epidural space. Two further attempts at removal, with the patient in the flexed lateral position, were unsuccessful. Under sterile conditions, the SnapLock adapter (Arrow International) was disconnected from the' catheter. The stylet from another FlexTip Plus catheter was lubricated with saline and threaded inside the lumen. Several attempts were required to reach the distal end of the catheter. Fluoroscopy showed partial uncoiling of the catheter tip. Simultaneous removal of the stylet and catheter was performed in the same lateral position and required minimal traction. We detected no abnormalities in the epidural catheter. The patient suffered no complications. The flexed lateral position is believed to facilitate the removal of a retained epidural catheter. 6 In this patient, however, there was no dlscernable change in the degree of entrapment with a move to the lateral position. W h e n the soft tissues of the back ensnare a flexible catheter, m u c h of the extractive force during traction is dissipated by the elasticity of the catheter. In the worst case, the distal part of the catheter remains immobile while the proximal part stretches until it breaks. The insertion of a stylet stiffens the catheter and allows the force applied by the operator to be transmitted more efficiently to the distal end. In addition, the stylet m a y prevent the formation of a knot by decreasing the coiling of the catheter tip. Both epidural stylets and fluoroscopy are readily available. We r e c o m m e n d this safe and simple technique in c a s e s of difficult epidural catheter removal. Alastair Ewen, ER.C.EC. Brian S. Kuwahara, ER.C.EC. R. Peter Farran, P.R.C.P.C. Department of Anesthesia Division of Pediatn'c Anesthesia University of Calgary Faculty of Medicine Alberta Children's Hospital Calgary, Alberta, Canada
208
Accepted for publication July 27, 1999.
The Mansour's Sacral Plexus Block: An Effective Technique for Continuous Block To the Editor: Before the description by Mansour of a parasacral approach, all the blocks of the sciatic nerve were considered peripheral blocks) Mansour's technique provides a real sacral plexus block that allows anesthesia of its main branches, tibial nerve, common peroneal nerve, and posterior cutaneous nerve of the thigh/"3 All previous techniques for continuous sciatic nerve block attempt to place a catheter after it has exited the pelvis. 3"~ Only two cases of continuous sciatic nerve block using the parasacral approach have been reported by Morris and Lang without any problem. 3 The theoretical (but unreported) risks of this technique are the perforation of iliac vessels, ureters, or rectum. 2 In 104 patients, Bruelle et aL have shown that the parasacacral approach is easy to perform, is reproductible, and produces a high success rate (98%) with minimal complicationsA In our institution, we insert sciatic catheters (POLYMEDIC tray i n d u d l n g a 21-gauge, insulated 90-ram needle and 24-gauge catheter) via the parasacral approach to provide postoperative analgesia after oncologic orthopedic surgery of the leg. Moreover, w h e n the saphenous nerve (lumbar plexus) is involved, we perform a single injection of local anesthesic near the vastus medialis nerve. In patients in the lateral decubitus position, the needle is inserted following landmarks described by Mansour. The localization of the sacral plexus is confirmed by the stimulation of one of the components of the sacral plexus: the c o m m o n peroneal nerve or tibial nerve. After the injection of 20 mL of bupivacaine with epinephrine 11200,000 and donidine 0.5 mcg.kg -j, a catheter is threaded through the needle approximately 7 to 8 crn and fixed to the skin with adhesive tape. After surgery, a solution containing contrast media (OMNIPAQUE) is systematically injected through the catheter. The typical spread 'of
RegionalAnesthesiaand Pain Medicine, Vo125, No 2 (March-April), 2000: pp 208-212
References
To the Editor:
l. Balance JH. Difficulty in the removal of an epidural catheter. Anaesthesia 1981,36:71-72. 2. Caldwell M, Dellaria S, Niedzwiecki C. Stretching of epidural nylon catheters on removal. Reg Anesth 1996;21:379-380. 3. Christie IW. Removal of lumbar extradural catheters. Br J Anaesth 1995;75:666. 4. Day C. Difficult removal of an epidural catheter. Anaesthesia 1993;48:448. 5. Shantha TR, Mani M. A simple method to retrieve irretrievable epidural catheters. Anesth Analg 1991;73:508-509. 6. Boey SK, Carrie LES. Withdrawal forces during removal of lumbar extradural catheters. Br J Anaesth 1994;73:833835.
Numerous reports have described epidural catheters that tenaciously resisted efforts at removal by traction alone. L2 Suggested solutions to the problem include such maneuvers as flexion of the spine, 3 injection of saline, 4 and retrieval through a second Tuohy needle? We wish to describe another technique that facilitated the removal of a stubborn epidural catheter. A 15-year-old gift presented with a retained 20-gauge midline lumbar epidural catheter (FlexTip Plus; Arrow International, Reading, PA), which had been inserted 3 days earlier for postoperative pain control. Repeated attempts at removal, with the patient in a flexed sitting position, produced a worrying degree of catheter stretch. She was brought to the operating room where the catheter was visualized using fluoroscopy. There was no evidence of knotting, but the distal 4 a n of the catheter was seen to be coiled within the epidural space. Two further attempts at removal, with the patient in the flexed lateral position, were unsuccessful. Under sterile conditions, the SnapLock adapter (Arrow International) was disconnected from the' catheter. The stylet from another FlexTip Plus catheter was lubricated with saline and threaded inside the lumen. Several attempts were required to reach the distal end of the catheter. Fluoroscopy showed partial uncoiling of the catheter tip. Simultaneous removal of the stylet and catheter was performed in the same lateral position and required minimal traction. We detected no abnormalities in the epidural catheter. The patient suffered no complications. The flexed lateral position is believed to facilitate the removal of a retained epidural catheter. 6 In this patient, however, there was no dlscernable change in the degree of entrapment with a move to the lateral position. W h e n the soft tissues of the back ensnare a flexible catheter, m u c h of the extractive force during traction is dissipated by the elasticity of the catheter. In the worst case, the distal part of the catheter remains immobile while the proximal part stretches until it breaks. The insertion of a stylet stiffens the catheter and allows the force applied by the operator to be transmitted more efficiently to the distal end. In addition, the stylet m a y prevent the formation of a knot by decreasing the coiling of the catheter tip. Both epidural stylets and fluoroscopy are readily available. We r e c o m m e n d this safe and simple technique in c a s e s of difficult epidural catheter removal. Alastair Ewen, ER.C.EC. Brian S. Kuwahara, ER.C.EC. R. Peter Farran, P.R.C.P.C. Department of Anesthesia Division of Pediatn'c Anesthesia University of Calgary Faculty of Medicine Alberta Children's Hospital Calgary, Alberta, Canada
208
Accepted for publication July 27, 1999.
The Mansour's Sacral Plexus Block: An Effective Technique for Continuous Block To the Editor: Before the description by Mansour of a parasacral approach, all the blocks of the sciatic nerve were considered peripheral blocks) Mansour's technique provides a real sacral plexus block that allows anesthesia of its main branches, tibial nerve, common peroneal nerve, and posterior cutaneous nerve of the thigh/"3 All previous techniques for continuous sciatic nerve block attempt to place a catheter after it has exited the pelvis. 3"~ Only two cases of continuous sciatic nerve block using the parasacral approach have been reported by Morris and Lang without any problem. 3 The theoretical (but unreported) risks of this technique are the perforation of iliac vessels, ureters, or rectum. 2 In 104 patients, Bruelle et aL have shown that the parasacacral approach is easy to perform, is reproductible, and produces a high success rate (98%) with minimal complicationsA In our institution, we insert sciatic catheters (POLYMEDIC tray i n d u d l n g a 21-gauge, insulated 90-ram needle and 24-gauge catheter) via the parasacral approach to provide postoperative analgesia after oncologic orthopedic surgery of the leg. Moreover, w h e n the saphenous nerve (lumbar plexus) is involved, we perform a single injection of local anesthesic near the vastus medialis nerve. In patients in the lateral decubitus position, the needle is inserted following landmarks described by Mansour. The localization of the sacral plexus is confirmed by the stimulation of one of the components of the sacral plexus: the c o m m o n peroneal nerve or tibial nerve. After the injection of 20 mL of bupivacaine with epinephrine 11200,000 and donidine 0.5 mcg.kg -j, a catheter is threaded through the needle approximately 7 to 8 crn and fixed to the skin with adhesive tape. After surgery, a solution containing contrast media (OMNIPAQUE) is systematically injected through the catheter. The typical spread 'of
RegionalAnesthesiaand Pain Medicine, Vo125, No 2 (March-April), 2000: pp 208-212