Tying the Knot in Labor and Delivery
Abstract Number: 61
Abstract Type: Case Report/Case Series
Introduction: A lumbar epidural catheter was placed for labor analgesia, used successfully for an uneventful vaginal delivery, and subsequently became difficult to remove due to development of a knot located 6mm from the tip. After unsuccessful attempts were made in the seated position, the catheter was eventually removed intact with the patient standing, flexed at the hip.
Case Report: A 30-year-old G3P2 woman was admitted at 39 weeks gestation in active labor with cervical dilation to 6cm. Her past medical history includes diet-controlled gestational diabetes mellitus. Two prior vaginal deliveries with epidural analgesia were uneventful. Successful midline placement of a PERIFIX FX 19 Ga. springwound closed-tip epidural catheter at the L2-3 interspace to 5cm was accomplished in the sitting position using a loss of resistance technique. Placement was successful on the third attempt. The epidural provided adequate labor analgesia for vaginal delivery. Following delivery, the anesthesiologist was called for epidural catheter removal due to significant resistance encountered upon attempted removal by nursing. After adequate time for 0.2% Ropivacaine to completely wear off, the catheter was removed by placing the patient in a standing position with maximal hip flexion. This occurred without incident or paresthesias and the catheter was noted to have a single knot located approximately 6mm from the tip.
Discussion: Knot formation is a rare complication of epidural catheter placement with an incidence of 1:30,000 (1). This complication may be best avoided by initially placing the catheter no more than 3-5cm within the epidural space. In several case reports, management of this suspected diagnosis includes steady traction with the patient awake in several positions or general anesthesia if no paresthesias are illicited. Should traction cause a paresthesia, there is a risk of nerve root avulsion. In this situation, radiologic evaluation including x-ray with contrast or guidewire, CT scan, or MRI should be considered. Surgical removal under anesthesia should also be strongly considered. Fortunately, the knotted epidural catheter was successfully removed from our patient with steady, gentle traction in a standing position flexed at the hips and without eliciting paresthesias.
1) Brichant JF, Bonhomme V, Hans P. On knots in epidural catheters: a case report and a review of the literature. International Journal of Obstetric Anesthesia 2006; 15:159-62.