Episode #26 Lumbar Drain Placement: The Case of the Stuck Guidewire

January 5, 2021

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Welcome to the next installment of the Anesthesia Patient Safety podcast hosted by Alli Bechtel.  This podcast will be an exciting journey towards improved anesthesia patient safety.

Do you have an anesthesia technology or device question or concern related to patient safety? Consider submitting your inquiry to the Rapid Response to questions from our readers. You can find the guide for authors here. https://www.apsf.org/apsf-newsletter/guide-for-authors/

Today, we are going to review an important case of a retained guidewire in a lumbar drain catheter leading to surgery delay. You can find the article here. https://www.apsf.org/article/inability-to-retract-guidewire-from-catheter-during-lumbar-csf-drain-placement-for-tevar-surgery/

Here are the references for the American and European recommendations for lumbar drain placement for spinal cord protection.

  1. Etz CD, Weigang E, Hartert M, et al. Contemporary spinal cord protection during thoracic and thoracoabdominal aortic surgery and endovascular aortic repair: a position paper of the vascular domain of the European Association for Cardio-Thoracic Surgery†. Eur J Cardiothorac Surg. 2015;47(6):943-957. doi:10.1093/ejcts/ezv142
  2. Hiratzka LF, Bakris GL, Beckman JA, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. 2010;121:e266–369.

We also look at how the Rapid Response Column got started by discussing the article from the October 2020 Newsletter, “Rapid Response and the APSF Mission.” You can find the article here. https://www.apsf.org/article/rapid-response-and-the-apsf-mission/

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© 2020, The Anesthesia Patient Safety Foundation

Hello and welcome back to the Anesthesia Patient Safety Podcast.  My name is Alli Bechtel and I am your host. Thank you for joining us for another show.

Today, we are going to return to one of my favorite sections of the APSF Newsletter, the Rapid Response to Questions from our readers. Have you ever had a question or concern about your anesthesia equipment or a device? You may find your answer in the Rapid Response to Questions from our readers column and if the answer is not there, we hope that you will consider submitting your inquiry for a future APSF Newsletter. I will include a link to the guide for authors in the show notes. This column was created in order to enable relatively quick communication of technology-related safety concerns from anesthesia professions who are using the technology for patient care with input and responses from manufacturers and industry representatives. The goal is to unite clinicians and industry representatives to discuss safety challenges and bring about changes when needed to improve patient safety.

Before we dive into today’s episode, we’d like to recognize Masimo, a major corporate supporter of APSF. Masimo has generously provided unrestricted support as well as research and educational grants to further our vision that “no one shall be harmed by anesthesia care”. Thank you, Masimo – we wouldn’t be able to do all that we do without you!”

I know you are all excited for the big reveal about what rapid response we will be discussing today, although the title of the show may have given it away. So, go ahead and click on the Patient Safety Resources heading on the APSF website, third one down is Rapid Response and the article is right at the top.

Today, we will be reviewing the article, “Inability to retract guidewire from catheter during lumbar CSF drain placement for TEVAR surgery” which was published online on September 9th of 2020. This article was submitted by Raza, Orion, Kelani, and Awad. Let’s get into the summary. Lumbar drain placement and cerebrospinal fluid or CSF drainage may be used to help prevent spinal cord ischemia during surgeries or procedures on the thoracic aorta including open repair of descending thoracic aortic aneurysm or a thoracic endovascular aortic repair or TEVAR procedure. Have you placed a lumbar drain as part of your anesthesia practice? This critical drain placement may involve placement of a catheter that contains a guidewire to facilitate placement. However, the guidewire may also lead to complications such as preventing placement of the lumbar drain and delaying surgery. This rapid response article seeks to evaluate the guidewire that is found in the lumbar drain kits including the design and composition as well as the rational for using a guidewire for placement. The authors present a case of a patient undergoing a TEVAR procedure who required lumbar drain placement when the guidewire that was included in the lumbar drain kit could not be retracted from the catheter.

Before we get to the case, let’s learn more about spinal cord injury during thoracic aortic aneurysm surgery. Patients undergoing repair of thoracic aortic aneurysms are at risk for ischemia to the spinal cord with resultant transient or permanent paresis or paralysis. One of the goals for improved patient safety during these procedures is to optimize spinal cord perfusion pressure. Spinal cord perfusion pressure is equal to the mean arterial blood pressure minus the intraspinal or CSF pressure which can be measured after the lumbar drain is placed. There are 2 ways to increase spinal cord perfusion pressure including increasing the mean arterial blood pressure and decreasing the CSF pressure which can decrease the risk for paralysis. There are American and European guidelines that recommend placement of a lumbar drain for spinal cord protection in order to monitor CSF pressure and drain CSF fluid when necessary to decrease CSF pressure for at least 48 hours for patients who have an open or endovascular thoracoabdominal aortic aneurysm repair. I will include the references in the show notes as well.

So, how is a lumbar drain placed? There are lumbar drain kits, including the Integra Hermetic Lumbar Catheter Closed Tip Kit used by the authors at their institution. There is a picture of the kit on our website included in this article. Once the spinal space is accessed by the appropriate-sized Tuohy, the catheter can be advanced through the Tuohy needle and into the spinal space. Placement of the CSF catheter may be performed with a guidewire that is inserted into the catheter to help advance the catheter and give the operator who is advancing the guidewire a tactile response to any resistance which may indicate an obstruction. The guidewire is made up of a nitinol or steel solid core wire, with nitinol preferred since it is more flexible and able to return to its original shape. Some guidewires may also have a coiled or braided wire around the core to help prevent kinking and increase flexibility. Guidewire construction may involve differences in the following tip shape, flexibility, torque, and steerability. The guidewire tip shape may be angled, straight or a “J” curve. After you open the lumbar drain kit, you may find a guidewire inside to help facilitate placement. In the lumbar drain kit used by the authors, there is a straight guidewire included which the authors used during placement of the lumbar drain. Unfortunately, the guidewire was unable to be removed following placement of the catheter.

Let’s take a closer look at this case. The authors report that a 70 year old woman presented for a TEVAR. Before induction, the lumbar drain was placed for CSF drainage and spinal cord protection. The Integra Hermetic Lumbar Catheter Closed Tip kit was used. Sterility was maintained as the catheter and guidewire were flushed and the guidewire was placed through the catheter. The patient was in the sitting position and skin was topicalized with 1% lidocaine. Then, a Tuohy spinal needle was placed into the subarachnoid space between the 3rd and 4th lumbar vertebrae with appropriate CSF flow. The next step involved uneventful placement of the catheter with the guidewire through the spinal needle to a depth of 15cm without resistance after which the Tuohy needle was removed. Then, with the catheter held in place at the insertion site, the guidewire was pulled back, but it failed to retract. Gentle traction was attempted along with increased force, but the guidewire could not be retracted. The team then decided to remove the catheter with the guidewire and this occurred without resistance. The team inspected the catheter and wire and found a lengthwise contraction of the catheter along the wire without any shearing of the catheter. The guidewire tip was still in the appropriate place at the catheter’s proximal end. At the distal end, there was excess wire observed and even with significant effort the authors were unable to remove the wire from the catheter. The patient tolerated the procedure well, but developed a headache due to loss of CSF through the Tuohy needle during the attempted lumbar drain placement. Her surgery and lumbar drain placement were delayed for 3 days. The subsequent successful lumbar drain placement was performed using fluoroscopy and the Radifocus Glidewire guidewire after which the patient underwent the TEVAR procedure and was later discharged home from the hospital.

This case brings up an important consideration, catheter contraction along a guidewire which is not a common event although you can find case reports of catheter shearing in the literature. However, the risk factors for catheter shearing may be applicable to catheter contraction as well and include catheter retraction through the needle during placement, faulty guidewire use, and excessive force for catheter removal. The authors note that the culprit in this case is likely the proximal end of the catheter and guidewire which failed to separate during guidewire retraction even though the catheter and wire were flushed appropriately prior to placement. Thus, it was the attempted retraction of the guidewire which caused the catheter contraction. There was a 2010 report involving the same lumbar drain kit with a similar event. The authors conclude that this event is due to the guidewire in the kit especially because the same catheter was used with a different guidewire, the hydrophilic Radifocus® Glidewire® with a floppy “J” tip and coaxial wrapping, during the patient’s successful lumbar drain placement. The authors leave us with a call to action for additional research to determine the optimal guidewire used for lumbar drain placement to prevent similar adverse events in the future.

Before we wrap up for today, I want to talk about an article from our October 2020 APSF Newsletter, “Rapid Response and the APSF Mission” by Jeffrey Feldman, the chair of the APSF Committee on Technology. The article opens by looking back to the very first article in the Rapid Response column entitled “Misplaced Valve Poses Potential Hazard” by James Berry and Steve Blanks which revealed an unexpected event of high airway pressures as a result of an occluded exhaust line from the scavenging system.  Further investigation revealed that the relief valve in the active scavenging system was actually a relief valve that was supposed to be used for the passive scavenging system according to Datex-Ohmeda and as a result of the inquiry, the company changed their assembly process so that this wouldn’t happen again. Even from the very beginning, the Rapid Response column established a collaboration between anesthesia professionals and anesthesia equipment manufacturers in order to identify a problem, work towards a solution, and provide the information in the APSF publication with its expansive anesthesia professionals readership. So, where did the APSF get the idea for the Rapid Response Column? It was created by Michael Olympio and Robert Morell. The original column name was Dear SIRS which stood for Safety Information Response System and thus the collaboration between industry and anesthesia professionals was forged.

Listeners of this podcast may know that I love top 10 lists, but today we are going to provide a supersized list.  So, without further ado, I give you the Top 25 Rapid Response articles on the APSF.org website according to page views. So, here we go:

  1. How do Flow Sensors Work?
  2. Humidity Levels in the OR
  3. Potential Burn Hazard from General Electric MRIs
  4. Reusable Anesthesia Breathing Circuits Considered
  5. Not All Manifolds are the Same: Lessons in Intravenous Drug Administration
  6. Dräger Fabius Leak Test Questioned
  7. Safety Issues With Gas Scavenging System in GE Avance and GE Aespire Anesthesia Machines
  8. Measurement of Expiratory Limb Circuit Pressure: A Potential Anesthesia Machine Safety Issue
  9. Why Do the Gauss Lines Matter?
  10. Line Isolation Still Important
  11. Volatile Anesthetic Unintentionally Not Delivered
  12. PEA Arrest During Transport of a Ventilated Patient Due to a Clogged Respiratory Filter on Ambu® Bag
  13. Reader Questions Why Some Anesthesia Machines Allow O2Flow Below Basal Metabolic Needs
  14. LTA Tip Breaks in Patient’s Airway
  15. Airway Topicalization Atomizer Parts Break Off in Patient’s Airway
  16. An Incident of GlideScope® Stat Cover Failure
  17. Nitrogen Contamination of Operating Room Oxygen Pipeline
  18. “No Read” Errors Related to Prefilled Syringes
  19. Perils and Pitfalls With the Rapid Infusion Catheter (RIC)
  20. O2Blender Causes Concern
  21. Descending Bellows Drives Question
  22. Defective Pediatric Endotracheal Tubes (ETTs)
  23. Burette Malpositioned Shut Off Valve Could Lead to Venous Air Embolism
  24. Defective Central Venous Catheter Introducer Needle
  25. Monitoring Gaps

Number 25 and Number 12 may sound familiar because we have talked about them on this podcast earlier for episode 8 when we discussed monitoring gaps and Episode 19 when we discussed the clogged respiratory filter on the Ambu Bag. And be sure to check back in the future because we will be covering more of these important topics related to anesthesia patient safety.

That’s all the time we have for today. If you have any questions or comments from today’s show, please email us at [email protected].

Visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.  Are you on Facebook? The APSF is on Facebook too!!  Head over there and like our page and follow along with us for more anesthesia patient safety related posts.

Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

© 2020, The Anesthesia Patient Safety Foundation