To the Editor
A healthy 19-year-old delivered a healthy infant vaginally with the benefit of epidural analgesia. During removal of the epidural catheter by the RN, the nurse noted that the catheter broke, leaving a portion of the catheter under the skin. The anesthesiologist evaluated the situation and noted that a piece of the plastic catheter had sheared off of the catheter’s wire winding. The retained catheter was not visible by x-ray, but a CT scan suggested that there was a 2 cm section of plastic catheter retained in the patient without retention of any residual wire. After a discussion with the patient regarding leaving in the catheter or removing it, the patient requested removal. It was thought that the catheter piece was stuck onto a facet.
The day after delivery, the patient was taken to the operating room and, under general anesthesia, the retained catheter piece was removed in its entirety. The patient recovered uneventfully and was discharged on the second postpartum day.
The epidural catheter used in this patient was manufactured by Arrow International. It is reported that such epidural catheters are rather difficult to break. The degree of tension on such a catheter that would result in breakage or fracture is unknown. Figure 1 shows the end of the plastic catheter and Figure 2 the remaining stretched wire.
It is easy to see the location where the plastic was sheared off of the wire. While this is the first broken catheter we have encountered, numerous instances of difficult catheter removal have occurred. The Arrow epidural catheters are quite pliable, enter the epidural space easily, are very rarely associated with intravascular migration, and in general are superior catheters compared to previous products. We have utilized a variety of strategies when difficulty in removing an epidural catheter is encountered. As a result of this catheter breaking, we have developed an algorithm for difficult epidural catheter removal that we would like to share:
1. If resistance is encountered in removing an epidural catheter, call for the anesthesiologist.
2. Utilizing gentle traction on the epidural catheter, place the patient in the position in which the epidural catheter was placed, and if unsuccessful, place the patient in multiple different positions, particularly those utilizing flexion of the lumbar spine.
3. If resistance to removal continues, wind the epidural catheter around a tongue blade under some tension (not enough to make it break) and tape the tongue blade to the patient’s back and come back in 15 to 20 minutes.
Our experience has been that this maneuver always results in a loosening of the catheter and it is then easily removed at that time. The longest we have ever had to leave the tongue blade taped to a patient’s back is 35 minutes. We removed one recalcitrant epidural catheter under fluoroscopic guidance and found that the same tongue blade technique was necessary even in that circumstance.
We would be interested in hearing if other practitioners have encountered any difficulty in removing this type of epidural catheter.
Gary L. Bonwell, MD
John Bentley, MD
James Evers, MD
Kurt Schroeder, MD
Carol Bratt, RN
Old Pueblo Anesthesia, Tucson, Arizona