Case Report – Accidental Epidural Catheter Breakage and Its Management

Aim: Epidural anaesthesia which is preferred in most of the prolonged and painful procedures can be dreadful when the catheter breaks inside. In this case report we report accidental breakage of epidural catheter and its successful management. Presentation of Case: 47 year old male patient was posted for arthroscopic Anterior cruciate ligament (ACL) and Posterior Cruciate Ligament (PCL) repair under spinal and epidural anesthesia. Epidural catheter got sheared while securing it. It was managed by surgical removal to avoid further complications. Discussion: There are different causes for epidural catheter breakage including technical error and manufacture error. Catheter should be checked for any manufacturing defect or kinking. If there is resistant while inserting the catheter careful removal of catheter along with the needle should be performed to avoid breakage of catheter. Conclusion: Epidural catheter breakage can be disastrous for any anaesthesiologist, so it is important to be vigilant while securing epidural catheter. If accidentally epidural catheter is retained it should be discussed with the patient and surgeons, and it is either removed since it is a foreign body or if left in situ. Serial follow-up for any neurological symptoms should be done.

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

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.

Simultaneous Brachial Plexus Block and Combined Two-Segment Spinal-Epidural Anesthesia with Fixation of an Epidural Catheter in the Subcutaneous Canal in a Patient with Polytrauma

The article reports an example of the simultaneous use of brachial plexus block and combined two-segment spinal-epidural anesthesia with fixation of an epidural catheter in the subcutaneous canal in an 81-year-old patient after receiving a household injury - closed fracture of the olecranon of the right ulna with displacement of fragments and closed transtrochanteric fracture with a fracture of the right femur fragments. After preoperative preparation and examination, the patient underwent two consecutive surgical interventions within a day: open reduction of comminuted transtrochanteric fracture of the right hip, dynamic femoral screw osteosynthesis and open reduction of fracture of the right olecranon, Weber’s osteosynthesis. Surgical interventions were carried out under regional anesthesia: block of the brachial plexus via supraclavicular access and combined two-segment spinal-epidural anesthesia with a method developed in our clinic for fixing an epidural catheter in the subcutaneous canal using a modified spinal needle. After the operation, the patient underwent postoperative pain relief in the form of epidural analgesia for 72 hours. The postoperative period passed without complications. On the 13th day, the patient was discharged for outpatient treatment by a traumatologist. The use of local anesthesia in the form of two methods of regional anesthesia during two consecutive surgical interventions, in an elderly patient with a high anesthetic risk, followed by long-term postoperative anesthesia in the form of epidural analgesia with a reliable method of epidural catheter fixation in the subcutaneous canal without the use of narcotic analgesics, contributed to the successful carrying out two surgical interventions at once, early activation of the patient, absence of complications in the postoperative period. Reliable catheter fixation is very important for the quality of epidural analgesia. Dislocation of catheters by more than 2 cm can lead to migration of catheters from the epidural space, changing the course of anesthesia, deteriorating its quality, or even interrupting it altogether. The new method of catheter fixation in the subcutaneous canal developed by us made it possible to prevent catheter dislocation.

Risk of Recurrent Venous Thromboembolism and Hemorrhage Following Interruption of Anticoagulation at Delivery

Background: Current guidelines for regional anesthesia advise for the discontinuation of prophylactic and therapeutic low molecular weight heparin (LMWH) 12 hours and 24 hours, respectively prior to the use of neuraxial anesthesia (NA) for obstetric patients. Re initiating a prophylactic dose 12 hours following epidural catheter insertion/spinal anesthesia (SA) and at least 4 hours following epidural catheter removal is also recommended. There are limited data on the recurrent risk of venous thromboembolism (VTE) and bleeding using these standards. We conducted a retrospective single center study to assess the risk of VTE and/or bleeding in pregnant women using these criteria. Methods: Consecutive patients from 2013 to 2018 at Mount Sinai Hospital, a university affiliated tertiary care center in Toronto, Canada who were prescribed therapeutic or prophylactic LMWH antenatally and postpartum and who had NA were included. Hospital records were reviewed to determine the indication and dosage of LMWH, presence of thrombophilia, time of first LMWH injection postpartum, the mode of neuraxial anesthesia and delivery, the time of epidural catheter/spinal anesthesia, the time of epidural catheter removal, laboratory parameters and comorbid illnesses. Patients requiring therapeutic or prophylactic LMWH were assessed in the Hematology clinic and were advised to discontinue anticoagulation according to current recommendations. The primary outcomes were frequency of VTE, spinal hematoma and volume of postpartum blood loss. Statistical Analysis: Continuous variables were summarized as medians and interquartile ranges. Categorical variables were summarized as percentages. Characteristics associated with VTE and hemorrhage were analyzed using regression analysis. Results: Of 169 pregnancies, 158 fulfilled criteria, and 110 had complete data for the time of epidural catheter removal and initiation of LMWH. Median age was 34 (IQR 5) years and median weight 90 (IQR 70) kgs. Diagnoses included antiphospholipid syndrome, Budd Chiari, provoked and unprovoked VTE. Median platelet count at delivery was 185 (IQR 76) x 10(9)/L. Thirty-three percent were using concomitant ASA antenatally. Forty-four percent (n=48) had a vaginal delivery (VD). Sixty five (59%) had epidural anesthesia, 43 (39%) had SA and, two had combined spinal/epidural anesthesia. Median time to restarting LMWH was 7.8 (IQR 4.7) hours from epidural catheter removal/spinal insertion and 9 (IQR 3.9) hours from SA. There were no spinal hematomas. Median blood loss was 500 (IQR 400) ml. One patient, who received prophylactic dose LMWH antepartum, had a Caesarean delivery, spinal anesthesia and a prophylactic dose re-started 13.7 hours after SA, developed a delayed postpartum hemorrhage. One patient developed a VTE (1%). She developed a distal and superficial thrombus immediately after delivery. She was using antenatal prophylactic LMWH as she had an unprovoked VTE predating pregnancy, was heterozygous for the prothrombin gene mutation, had epidural anesthesia and VD. She received prophylactic LMWH three hours after catheter removal which was also 10 hours after catheter insertion. Limitations: Time of discontinuation of LMWH prior to induction could not be confirmed definitively as this was a retrospective review. Conclusion: Prospective studies are required to confirm these findings and to determine the safety of current recommendations of interrupting anticoagulation prior to regional anesthesia and delivery and to identify risk factors for hemorrhage and recurrent VTE to optimize anticoagulation regimens for these patients. Disclosures Malinowski: Alexion: Honoraria, Membership on an entity's Board of Directors or advisory committees; Pfizer: Consultancy.