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 Table of Contents  
LETTER TO THE EDITOR
Year : 2020  |  Volume : 7  |  Issue : 2  |  Page : 250-251

Check at every point: failed epidural catheter owing to stretching


1 Department of Anaesthesia, Government Medical College and Hospital, Chandigarh, India
2 Department of Orthopaedics, Gian Sagar Medical College, Punjab, India

Date of Submission23-Apr-2019
Date of Acceptance16-Dec-2019
Date of Web Publication27-Jun-2020

Correspondence Address:
MD Ravneet K Gill
Department of Anaesthesia, Government Medical College and Hospital, Chandigarh, Postal Zip Code 160031
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/roaic.roaic_41_19

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How to cite this article:
Gill RK, Rathi U, Saroa R, Mudgal A. Check at every point: failed epidural catheter owing to stretching. Res Opin Anesth Intensive Care 2020;7:250-1

How to cite this URL:
Gill RK, Rathi U, Saroa R, Mudgal A. Check at every point: failed epidural catheter owing to stretching. Res Opin Anesth Intensive Care [serial online] 2020 [cited 2020 Jul 7];7:250-1. Available from: http://www.roaic.eg.net/text.asp?2020/7/2/250/287990

Sir,

Epidural maintenance failure after insertion may be multifactorial, primarily arising from knotting, kinking, and obstruction, usually as result of abutting to skin or pinching off at the filter [1]. Relatively rare causes like obstruction of catheter by a blood clot or manufacturing defects are also mentioned in the literature [2]. We hereby report a case where epidural catheter underwent stretching secondary to entrapment of the catheter assembly in the hinge of the operating table that went unnoticed intraoperatively and led to obliteration of the lumen thereby leading to failure of the maintenance in the postoperative period

An 18-year-old male patients with displaced fracture femur and undisplaced fracture of left clavicle on radiological examination was scheduled to undergo closed intramedullary nailing under combined spinal epidural anesthesia. CSEA was performed in the sitting position under aseptic conditions. Epidural block (Epidural Minipack System 1, Portex USA) was given at the level of L2–L3 interspace after achieving loss of resistance to air at 5 cm from skin. The epidural catheter was fixed at 11 cm. Subarachanoid block was achieved with 26-G spinal needle at L3–L4 interspace and 3 ml of 0.5% bupivacaine. Catheter was fixed using a sterile dressing. After positioning of the patient, the patency of epidural catheter was assessed by injecting 1 ml of normal saline. The short duration of surgery (around 150 min) was uneventful and did not warrant the need for epidural boluses in the intraoperative period. As per the institutional protocol, the patient was supposed to be rendered to acute pain services in the postoperative period. However, on repositioning the patient, abnormal lengthening of epidural catheter was observed secondary to accidental entrapment of the connector catheter assembly in the hinge of the operating table. As the lumen of the epidural catheter had been obliterated by the abnormal lengthening making it impossible to infuse fluid through it, it was decided to remove the catheter and provide alternate method of pain relief to the patient. Interestingly, catheter fixation was intact at the skin as before, which was confirmed after removal of the adhesive dressing. Thinned-out catheter had a distinct feel and distinct point differentiating it from the normal lumen ([Figure 1]). In an attempt to use the indwelling catheter, we transected the catheter beyond the constriction with a sterile blade and were able to deliver the drug without any resistance. However, it had to be removed owing to discomfort caused by catheter assembly at the back after injecting a bolus of 0.125% bupivacaine and 2 μg/ml fentanyl (10 ml) to provide postoperative pain relief in addition to multimodal analgesia. The catheter length was measured to be 122 cm after removal in contrast to the normal length of 100 cm ([Figure 2]).
Figure 1 Difference in caliber in normal (above) catheter and stretched-out catheter.

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Figure 2 Difference in length of catheter.

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Epidural catheter failure is a dreaded complication which may occur secondary to kinking, knotting, displacement, occlusion of catheter (blood clot or connector assembly) or manufacturing defect. In the present case, the catheter was stretched out leading to thinning as well as obliteration of the lumen, making it impossible to administer the drug. We hypothesize that the peculiar cause of obliteration secondary to entrapment in the hinge of the operating table during positioning might have led to undue shearing effect on the catheter, exceeding its tensile strength, resulting in abnormal lengthening as well as thinning. Stretching and thinning of epidural catheter has been reported earlier also, but the exact cause has not been established [3].

In the present case, polyamide epidural catheter was employed during insertion. Nylon and polyurethane catheters are relatively more resistant than Teflon or polyethylene catheters [4]. It has been documented that polyamide and polyurethane catheters can stretch up to 300% of their length before breakage in comparison with 30% to synthetic fiber epidural catheters [5].

Thus, in addition to the commonly encountered causes, we must rule out the rare causes of catheter malfunction and should be extremely vigilant while positioning the patient. The residents must be sensitized to recheck the catheter after positioning, and we recommend the flushing of the catheter with normal saline to detect the same at the earliest, so as not deprive the patients of its benefits.

Acknowledgements

The authors are thankful to the Department of Anesthesia at a Government Medical College in Chandigarh, India, for support.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Uchino T, Miura M, Oyama Y, Matsumoto S, Shingu C, Kitano T. Lateral deviation of four types of epidural catheters from the lumbar epidural space into the intervertebral foramen. J Anesth 2016; 30:583–590.  Back to cited text no. 1
    
2.
Hung K-C. Epidural catheter blockage caused by a blood clot: is it time to change our practice? J Clin Anesth 2016; 35:205–206.  Back to cited text no. 2
    
3.
Fred KK, Frank AK, Judith F. Stretching with obstruction of an epidural catheter. Anesth Analg 1987; 66:1202–1203.  Back to cited text no. 3
    
4.
de Souza HAB. Breakage of epidural catheters: etiology, prevention, and management. Rev Bras Anestesiol 2008; 58:227–233.  Back to cited text no. 4
    
5.
Ates Y, Yucesoy CA, Unlu MA, Saygin B, Akkas N. The mechanical properties of intact and traumatized epidural catheters. Anesth Analg 2000; 90:393–399.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2]



 

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