Accidental Epidural Catheter Removal Rates and Strength Required for Disconnection: a Retrospective Cohort and Experimental Study

Abstract Background: Epidural analgesia requires the use of epidural catheters, which are associated with certain risks such as accidental epidural catheter removal, including dislodgement and disconnection. Few studies have investigated accidental catheter removal rates and directly compared them among epidural connector types. This study aimed to examine the differences in accidental catheter removal rates associated with different catheter connector types and to experimentally determine the linear tensile strength required to induce disconnection in each connector type.Methods: This retrospective cohort study included adult patients who underwent elective surgery and received patient-controlled epidural analgesia between December 2019 and August 2020. Patients were divided into groups according to the type of catheter connection used: standard (old group), new standard (new group), and new standard with taping (taping group). Furthermore, we prepared 60 sets of epidural catheters and connectors comprising 20 sets for each of the old, new, and taping groups, and used the digital tension meter to measure the maximum tensile strength required to induce disconnection. A multinomial logistic regression analysis was used to examine risk factors for disconnection. The experimental study groups were compared using one-way analysis of variance.Results: The clinical study involved in 920 patients (360, 182, and 378 patients in the old, new, and taping group, respectively). Dislodgement rates were similar among the three groups. Disconnection was most likely to occur in the new group (5.5%) and least likely to occur in the taping group (0.3%) compared to the old group (1.9%). However, the new group was not a risk factor for disconnection. The experimental study identified tensile strengths of 12.41 N, 12.06 N, and 19.65 N in the old, new, and taping groups, respectively. Comparison tests showed a significant difference in the tensile strength required for disconnection between the new and taping groups but not between the new and old groups.Conclusions: These findings suggest that taping the catheter connector connection may reduce the risk of disconnection, and thereby help improve patient outcomes. Further studies are required to clarify other parameters that may affect patient safety in this context.

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Clinical and Bacteriologic Survey of Epidural Analgesia in Patients in the Intensive Care Unit

Anesthesiology ◽

10.1097/00000542-199611000-00005 ◽

1996 ◽

Vol 85 (5) ◽

pp. 988-998 ◽

Cited By ~ 71

Author(s):

Bruno Darchy ◽

Xavier Forceville ◽

Eric Bavoux ◽

Frederic Soriot ◽

Yves Domart

Keyword(s):

Risk Factors ◽

Intensive Care Unit ◽

Intensive Care ◽

Epidural Analgesia ◽

Epidural Catheter ◽

Strong Predictor ◽

Insertion Site ◽

Space Infection ◽

General Signs ◽

Epidural Catheters

Background The risk of bacterial contamination related to epidural analgesia in patients cared for in the intensive care unit has not been assessed. Thus the authors studied patients who received care in the intensive care unit who were given epidural analgesia for more than 48 h to determine the rates of local, epidural catheter, and spinal space infection and to identify risk factors. Methods Each patient receiving epidural analgesia for longer than 48 h was examined daily for local and general signs of infection. A swab sample for culture was taken if there was local discharge; all epidural catheters were cultured on withdrawal. All patients underwent weekly neurologic monitoring for 1 month; those with positive epidural catheter cultures had one spinal magnetic resonance image scan. Results The 75 patients cared for in the intensive care unit who were studied had been receiving epidural analgesia for a median of 4 days (interquartile range, 3.5 to 5 days). Twenty-seven patients had signs of local inflammation (erythema or local discharge), and nine of these had infections. All the patients who had both local signs also had infection. All nine infections were local (12%), but four patients also had epidural catheter infections (5.3%). No patient with erythema alone or without local signs had a positive epidural catheter culture. No spinal space infection was diagnosed. Staphylococcus epidermidis was the most frequently cultured microorganism. Local infection was treated by removing the epidural catheter without any antibiotics. Concomitant infection at other sites (21 of 75 patients, or 28%), antibiotic therapy (64 of 75 patients, or 85%), the duration of epidural analgesia, and the insertion site level of the epidural catheter were not identified as risk factors for epidural analgesia-related infections. Conclusions The risk of epidural analgesia-related infection in patients in the intensive care unit seems to be low. The presence of two local signs of inflammation is a strong predictor of local and epidural catheter infection.

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Incidence of Epidural Catheter-associated Infections after Continuous Epidural Analgesia in Children

Anesthesiology ◽

10.1097/aln.0b013e3181de6cc5 ◽

2010 ◽

Vol 113 (1) ◽

pp. 224-232 ◽

Cited By ~ 33

Author(s):

Navil F. Sethna ◽

David Clendenin ◽

Umeshkumar Athiraman ◽

Jean Solodiuk ◽

Diana P. Rodriguez ◽

...

Keyword(s):

Chronic Pain ◽

Postoperative Pain ◽

Epidural Analgesia ◽

Epidural Catheter ◽

Medical Decision ◽

Incidence Data ◽

Serious Infections ◽

Continuous Epidural Analgesia ◽

Pediatric Populations ◽

Epidural Catheters

Clinical observation suggests that the number of serious epidural catheter-associated infections have increased recently in children. This increase is likely attributed to an increase in reporting and in frequency of epidural analgesia usage. Estimates of infection rates are difficult to determine primarily because of insufficient study of large pediatric populations. In this retrospective study, the authors investigated the incidence of epidural catheter-associated soft tissue and epidural infections after use of continuous epidural analgesia spanning 17 yr. A total of 10,653 epidural catheters were used in 7,792 children. The majority of catheters, 10,437 (98%), were placed for the management of postoperative pain, and 216 (2%) were placed for the management of chronic pain. The authors identified 13 cases of infections (nine cellulitis, two paravertebral musculature infections, one epidural inflammation, and one epidural abscess) between 3 and 11 days after catheter insertion. The incidence of infection was significantly higher in patients treated for chronic pain (7 of 216 = 3.2%) compared with postoperative pain (6 of 10,437 = 0.06%; P < 0.0001). Surgical drainage of subcutaneous pus was performed in three patients, and medical therapy was administered in the remainder of patients; all patients recovered without sequelae. Although rare, epidural catheter-associated infections remain a serious concern in high-risk children who may benefit the most from epidural analgesia. The findings of the authors support the low rate of epidural infection previously reported despite growing concerns of serious infections in children. These findings highlight the importance of vigilance to early diagnostic indicators of infection and provide practitioners and families with incidence data to guide informed medical decision-making.

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Prospective Examination of Epidural Catheter Insertion

Anesthesiology ◽

10.1097/00000542-199601000-00011 ◽

1996 ◽

Vol 84 (1) ◽

pp. 88-93 ◽

Cited By ~ 61

Author(s):

Robert D'Angelo ◽

Brenda L. Berkebile ◽

J. C. Gerancher

Keyword(s):

Epidural Analgesia ◽

Epidural Catheter ◽

Cesarean Delivery ◽

Epidural Space ◽

Local Anesthetic ◽

Catheter Insertion ◽

Labor And Delivery ◽

Prolonged Labor ◽

Epidural Catheters ◽

Insertion Length

Background Although it is generally accepted that inserting epidural catheters 3-4 cm into the epidural space minimizes complications, no prospective randomized examination of epidural catheter insertion length has been published. Methods Eight hundred healthy parturients requesting epidural analgesia were randomized to have open-tip epidural catheters inserted 2, 4, 6, or 8 cm within the epidural space. The incidences of intravenous cannulation, unilateral sensory analgesia, and subsequent catheter dislodgment were recorded. Catheter insertions that resulted in intravenous cannulation or unilateral analgesia were incrementally withdrawn and retested with additional local anesthetic to determine the effectiveness of epidural catheter manipulation. Results Epidural catheters inserted 8 cm within the epidural space were more likely to result in intravenous cannulation. Epidural catheters inserted 2 cm within the epidural space were less likely to result in unilateral sensory analgesia but were more likely to become dislodged. Twenty-three percent of epidural catheters inserted > 2 cm within the epidural space required manipulation. Epidural catheters inserted 2 or 4 cm required replacement more often than epidural catheters inserted 6 or 8 cm. Ninety-one percent and 50% of epidural catheters that resulted in unilateral sensory analgesia and intravenous cannulation, respectively, provided analgesia for labor and delivery after incremental withdrawal. Conclusions Epidural catheters should be inserted either 2 cm when rapid labor is anticipated or 6 cm when prolonged labor or cesarean delivery is likely. Additionally, epidural catheters that result in intravenous cannulation or unilateral sensory analgesia can be manipulated effectively to provide analgesia for labor and delivery.

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Success of Spinal and Epidural Labor Analgesia

Anesthesiology ◽

10.1097/aln.0b013e3181a4c6f2 ◽

2009 ◽

Vol 111 (1) ◽

pp. 165-172 ◽

Cited By ~ 30

Author(s):

Lydia S. Grondin ◽

Kenneth Nelson ◽

Vernon Ross ◽

Orlando Aponte ◽

Sherman Lee ◽

...

Keyword(s):

Epidural Analgesia ◽

Epidural Catheter ◽

Labor Analgesia ◽

Drug Consumption ◽

Spinal Needle ◽

Spinal Analgesia ◽

Clear Fluid ◽

Epidural Catheters ◽

Spinal Epidural ◽

Catheter Replacement

Background Comparison of air versus saline for loss of resistance technique (LORT) in combined spinal epidural labor analgesia (CSE) has not been evaluated, and neither has the relation between CSE characteristics (the presence/absence of initial spontaneous clear fluid return or upon aspiration) and spinal/epidural analgesia outcomes. The authors hypothesized that there is no difference in the spinal analgesia success or epidural catheter efficacy between using air versus saline LORT for CSE. Methods A total of 360 patients were randomized to air or saline LORT for CSE. Primary outcome was spinal analgesia success as defined by verbal pain score of no more than 3 at 15 min after spinal dose administration. Secondary outcomes were CSE characteristics, catheter replacement, and average hourly epidural drug consumption. Results Results from 345 patients were analyzed. Spinal analgesia success, epidural catheter replacement, and drug consumption were not different between using air or saline LORT and were also independent of the presence/absence of fluid return on aspiration if initial spontaneous fluid returned to the spinal needle. However, epidural catheters inserted in absence of initial fluid return had a significantly higher catheter replacement rate (28.6%) than the 4.1% among those with initial fluid return (P < 0.03). Conclusions Spinal analgesia success rate and epidural efficacy are independent of whether air or saline is used for LORT during CSE. Practice of aspiration for fluid after observing initial fluid return may be unnecessary because this practice does not alter spinal/epidural analgesia outcomes. However, epidural catheters inserted with the absence of initial fluid returned to spinal needle may pose a high failure risk.

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Epidural Analgesia in the Management of Severe Vaso-Occlusive Sickle Cell Crisis

PEDIATRICS ◽

10.1542/peds.93.2.310 ◽

1994 ◽

Vol 93 (2) ◽

pp. 310-315 ◽

Cited By ~ 1

Author(s):

Myron Yaster ◽

Joseph R. Tobin ◽

Carol Billett ◽

James F. Casella ◽

George Dover

Keyword(s):

Epidural Analgesia ◽

Oxygen Saturation ◽

Epidural Catheter ◽

Respiratory Depression ◽

Sickle Cell ◽

Local Anesthetic ◽

Analgesic Therapy ◽

Plasma Lidocaine ◽

Continuous Epidural Analgesia ◽

Epidural Catheters

Objectives. To determine whether continuous epidural analgesia could effectively decrease pain and thereby improve the management of severe vaso-occlusive crisis in children with sickle cell disease who were unresponsive to conventional analgesic therapy. Design. Retrospective observational study. Setting. A tertiary care hospital with a large pediatric sickle cell patient referral population. Patients. The study describes nine children in 11 painful vaso-occlusive crises, unresponsive to high-dose systemic opioids, nonsteroidal anti-inflammatory drugs, and adjunctive measures, who underwent continuous epidural analgesia to control pain. Outcome Measures. Subjective pain scores, arterial oxygen saturation monitoring, and plasma lidocaine levels. Methods. Placement of an epidural catheter for the administration of a continuous infusion of local anesthetic, alone, or in combination with fentanyl, in the management of vaso-occlusive crisis. Results. At initiation of epidural analgesic therapy, 8 of 9 patients reported severe pain (8 to 10 on a scale of 0 to 10, 0 = no pain, 10 = the worst pain they ever experienced). Analgesia was immediate (pain score 0 to 2) in 8 of 9 patients, and continuously effective in 9 of 11 crises. Five patients required either the addition of fentanyl or changing the local anesthetic from lidocaine to bupivacaine to maintain analgesia for 2 to 5 days. In 7 of 9 patients, oxygen saturation dramatically increased from 87 to 95% to 99 to 100% after epidural analgesia was initiated. In all patients, plasma lidocaine levels ranged from 1.1 to 4.6 mg/L and dose-related toxicity did not occur. One patient developed hypotension secondary to high sympathetic blockade (T-4), one had an inadvertent dural puncture during insertion of the catheter, one had the epidural catheter removed for fever, and one achieved analgesia only transiently. There were no other complications, and epidural analgesia was not associated with sedation, respiratory depression, or limitation of movement. All epidural catheters were cultured on removal, and colonization did not occur. Conclusions. Epidural analgesia with local anesthetics administered alone or in combination with fentanyl effectively and safely treats the pain of sickle cell vaso-occlusive crisis unresponsive to conventional pain management and does so without causing sedation, respiratory depression, or significant limitation on ambulation. Furthermore, early treatment of painful crisis with this technique may improve oxygenation, a critical factor in the evolution of further sickling.

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Anticoagulant Effect at the Time of Epidural Catheter Removal in Patients Receiving Twice-daily or Once-daily Low-molecular-weight Heparin and Continuous Epidural Analgesia after Orthopedic Surgery

Thrombosis and Haemostasis ◽

10.1055/s-0037-1613150 ◽

2002 ◽

Vol 88 (07) ◽

pp. 37-40 ◽

Cited By ~ 21

Author(s):

Krystyna Kinnon ◽

Mark Crowther ◽

James Douketis

Keyword(s):

Molecular Weight ◽

Epidural Analgesia ◽

Epidural Catheter ◽

Orthopedic Surgery ◽

Low Molecular Weight Heparin ◽

Anticoagulant Effect ◽

Catheter Removal ◽

Low Molecular Weight ◽

Once Daily ◽

Continuous Epidural Analgesia

SummaryIn patients who receive co-administered low-molecular-weight heparin (LMWH) and continuous epidural analgesia (CEA) after orthopedic surgery, there is concern about an increased risk of a spinal epidural hematoma. The practice of twice-daily LMWH dosing in North America might, in part, account for the greater number of epidural hematomas reports compared to Europe where once-daily LMWH is used. We performed a prospective cohort study in patients who had orthopedic surgery and received co-administered LMWH and CEA. We investigated the trough anticoagulant effect, as measured by an anti-Xa heparin level, at the time of epidural catheter removal in patients who received twice-daily or once-daily LMWH. Twenty-five patients who received enoxaparin, 30 mg twice-daily, and 25 patients who received dalteparin, 5,000 IU once-daily, had anti-Xa heparin levels measured on the second or third post-operative day at the time of epidural catheter removal. In patients who received twice-daily enoxaparin, or once-daily dalteparin, the anti-Xa heparin level was measured, on average, 10.4 h and 21.8 h, respectively, after the preceding LWMH dose. All 25 patients who received once-daily LMWH had an anti-Xa heparin level <0.10 U/ml at the time of catheter removal. Of 25 patients who received twice-daily LMWH, the anti-Xa heparin level at the time of catheter removal was >0.20 U/ml in 5 patients (P = 0.050), and >0.10 U/ml in 7 patients (P = 0.009). We conclude that in patients who are receiving co-administered LMWH and CEA after orthopedic surgery, twice-daily but not once-daily LMWH administration is more likely to be associated with a clinically important anticoagulant effect at the time of epidural catheter removal.

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Tumour Metastasis at the Site of a Previous Epidural Catheter

Anaesthesia and Intensive Care ◽

10.1177/0310057x0803600618 ◽

2008 ◽

Vol 36 (6) ◽

pp. 863-866

Author(s):

M. M. Chappell ◽

H. A. Schoengen

Keyword(s):

Bladder Cancer ◽

Case Report ◽

Epidural Analgesia ◽

Epidural Catheter ◽

Radical Cystectomy ◽

Emergency Surgery ◽

Vertebral Level ◽

Tumour Metastasis ◽

Continuous Epidural Analgesia ◽

Epidural Catheters

Epidural catheters can cause a number of rare, serious complications. The following case report describes a patient who received continuous epidural analgesia following radical cystectomy for bladder cancer. Fifty-three days after the cystectomy, the patient underwent emergency surgery for a metastasis at the vertebral level where the epidural catheter had been inserted. A metastasis at the site of an epidural catheter, which may be a direct complication of epidural analgesia, is a previously unreported event. Local, anatomical and pathological factors which may have led to the patient developing a metastasis at the epidural site are discussed.

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Nonunion Rates in Hind- and Midfoot Arthrodesis in Current, Ex-, and Nonsmokers

Foot & Ankle International ◽

10.1177/1071100720971269 ◽

2020 ◽

pp. 107110072097126

Author(s):

Jack Allport ◽

Jayasree Ramaskandhan ◽

Malik S. Siddique

Keyword(s):

Risk Factor ◽

Cohort Study ◽

Relative Risk ◽

Retrospective Cohort Study ◽

Retrospective Cohort ◽

Smoking Status ◽

Time Frame ◽

Modifiable Risk Factor ◽

Level Of Evidence ◽

Significant Difference

Background: Nonunion rates in hind or midfoot arthrodesis have been reported as high as 41%. The most notable and readily modifiable risk factor that has been identified is smoking. In 2018, 14.4% of the UK population were active smokers. We examined the effect of smoking status on union rates for a large cohort of patients undergoing hind- or midfoot arthrodesis. Methods: In total, 381 consecutive primary joint arthrodeses were identified from a single surgeon’s logbook (analysis performed on a per joint basis, with a triple fusion reported as 3 separate joints). Patients were divided based on self-reported smoking status. Primary outcome was clinical union. Delayed union, infection, and the need for ultrasound bone stimulation were secondary outcomes. Results: Smoking prevalence was 14.0%, and 32.2% were ex-smokers. Groups were comparable for sex, diabetes, and body mass index. Smokers were younger and had fewer comorbidities. Nonunion rates were higher in smokers (relative risk, 5.81; 95% CI, 2.54-13.29; P < .001) with no statistically significant difference between ex-smokers and nonsmokers. Smokers had higher rates of infection ( P = .05) and bone stimulator use ( P < .001). Among smokers, there was a trend toward slower union with heavier smoking ( P = .004). Conclusion: This large retrospective cohort study confirmed previous evidence that smoking has a considerable negative effect on union in arthrodesis. The 5.81 relative risk in a modifiable risk factor is extremely high. Arthrodesis surgery should be undertaken with extreme caution in smokers. Our study shows that after cessation of smoking, the risk returns to normal, but we were unable to quantify the time frame. Level of Evidence: Level III, retrospective cohort study.

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387. Markers for Mortality in COVID-19 Patients with Atrial Fibrillation or Flutter

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.582 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S262-S262

Author(s):

Kok Hoe Chan ◽

Bhavik Patel ◽

Iyad Farouji ◽

Addi Suleiman ◽

Jihad Slim

Keyword(s):

Atrial Fibrillation ◽

Logistic Regression ◽

Cohort Study ◽

Retrospective Cohort Study ◽

Retrospective Cohort ◽

Prognostic Markers ◽

Univariate Analysis ◽

Laboratory Data ◽

Significant Difference ◽

New Onset

Abstract Background Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection can lead to many different cardiovascular complications, we were interested in studying prognostic markers in patients with atrial fibrillation/flutter (A. Fib/Flutter). Methods A retrospective cohort study of patients with confirmed COVID-19 and either with existing or new onset A. Fib/Flutter who were admitted to our hospital between March 15 and May 20, 2020. Demographic, outcome and laboratory data were extracted from the electronic medical record and compared between survivors and non-survivors. Univariate and multivariate logistic regression were employed to identify the prognostic markers associated with mortality in patients with A. Fib/Flutter Results The total number of confirmed COVID-19 patients during the study period was 350; 37 of them had existing or new onset A. Fib/Flutter. Twenty one (57%) expired, and 16 (43%) were discharged alive. The median age was 72 years old, ranged from 19 to 100 years old. Comorbidities were present in 33 (89%) patients, with hypertension (82%) being the most common, followed by diabetes (46%) and coronary artery disease (30%). New onset of atrial fibrillation was identified in 23 patients (70%), of whom 13 (57%) expired; 29 patients (78%) presented with atrial fibrillation with rapid ventricular response, and 2 patients (5%) with atrial flutter. Mechanical ventilation was required for 8 patients, of whom 6 expired. In univariate analysis, we found a significant difference in baseline ferritin (p=0.04), LDH (p=0.02), neutrophil-lymphocyte ratio (NLR) (p=0.05), neutrophil-monocyte ratio (NMR) (p=0.03) and platelet (p=0.015) between survivors and non-survivors. With multivariable logistic regression analysis, the only value that had an odds of survival was a low NLR (odds ratio 0.74; 95% confidence interval 0.53–0.93). Conclusion This retrospective cohort study of hospitalized patients with COVID-19 demonstrated an association of increase NLR as risk factors for death in COVID-19 patients with A. Fib/Flutter. A high NLR has been associated with increased incidence, severity and risk for stroke in atrial fibrillation patients but to our knowledge, we are first to demonstrate the utilization in mortality predictions in COVID-19 patients with A. Fib/Flutter. Disclosures Jihad Slim, MD, Abbvie (Speaker’s Bureau)Gilead (Speaker’s Bureau)Jansen (Speaker’s Bureau)Merck (Speaker’s Bureau)ViiV (Speaker’s Bureau)

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The change of coagulation profile in two-staged arthroplasty for periprosthetic joint infection patients: a retrospective cohort study

Journal of Orthopaedic Surgery and Research ◽

10.1186/s13018-021-02477-4 ◽

2021 ◽

Vol 16 (1) ◽

Author(s):

Hao Li ◽

Rui Li ◽

L. L. Li ◽

Wei Chai ◽

Chi Xu ◽

...

Keyword(s):

Cohort Study ◽

Periprosthetic Joint Infection ◽

Retrospective Cohort Study ◽

Persistent Infection ◽

Retrospective Cohort ◽

Joint Infection ◽

Diagnostic Study ◽

Level Of Evidence ◽

Coagulation Profile ◽

Significant Difference

Abstract Aims Periprosthetic joint infection (PJI) is a serious complication of total joint arthroplasty. We performed a retrospective cohort study to evaluate (1) the change of coagulation profile in two-staged arthroplasty patients and (2) the relationship between coagulation profile and the outcomes of reimplantation. Method Between January 2011 and December 2018, a total of 202 PJI patients who were operated on with two-staged arthroplasty were included in this study initially. This study continued for 2 years and the corresponding medical records were scrutinized to establish the diagnosis of PJI based on the 2014 MSIS criteria. The coagulation profile was recorded at two designed points, (1) preresection and (2) preimplantation. The difference of coagulation profile between preresection and preimplantation was evaluated. Receiver operating characteristic curves (ROC) were used to evaluate the diagnostic efficiency of the coagulation profile and change of coagulation profile for predicting persistent infection before reimplantation. Results The levels of APTT, INR, platelet count, PT, TT, and plasma fibrinogen before spacer implantation were significantly higher than before reimplantation. No significant difference was detected in the levels of D-dimer, ACT, and AT3 between the two groups. The AUC of the combined coagulation profile and the change of combined coagulation profile for predicting persistent infection before reimplantation was 0.667 (95% CI 0.511, 0.823) and 0.667 (95% CI 0.526, 0.808), respectively. Conclusion The coagulation profile before preresection is different from before preimplantation in two-staged arthroplasty and the coagulation markers may play a role in predicting infection eradication before reimplantation when two-stage arthroplasty is performed. Level of evidence Level III, diagnostic study.

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