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///2013 Abstract Details
2013 Abstract Details2019-08-02T16:57:45-05:00

Incidence and Management of Difficulty Advancing Arrow FlexTip Plus® Epidural Catheters

Abstract Number: T 14
Abstract Type: Original Research

Hans P Sviggum M.D.1 ; Michaela K Farber MD2

INTRODUCTION: Difficulty advancing an epidural catheter has been reported to occur in 0-7% of epidural placements. Despite the increased use of soft flexible catheters to reduce paresthesias and intravascular catheter placements, the inability to advance these catheters remains undefined. Specifically, the incidence of this problem and effective management strategies has not been described.

METHODS: All lumbar epidural catheters placed on the labor floor by participating anesthesiologists (residents, fellows, and staff) were recorded for a 12-week period. Difficulty in advancing the epidural catheter was defined as an inability to advance the catheter beyond the needle tip after obtaining loss-of-resistance. Anesthesiologists recorded every catheter placement and completed an additional data sheet when an inability to advance the epidural catheter occurred.

RESULTS: A total of 1200 epidural catheter placements (982 epidural, 218 combined spinal-epidural) were performed during the study period. There were 54 cases of difficult catheter advancement (4.5%; 95% CI=3.4-5.8%). A total of 108 corrective maneuvers (17 single, 23 double, 8 triple, and 5 quadruple) were performed (Table 1). Difficult catheter advancement occurred in 3.2% of combined spinal-epidural and 4.8% of epidural placements (OR=0.66; 95% CI=0.29 to 1.48; p=0.313). On a scale of 0 to 10, median (Q1, Q3) provider confidence in loss-of-resistance was 9 (7, 10). The incidence of inadvertent dural puncture was 3 in 54 (5.6%) if difficult catheter advancement occurred compared to 9 in 1146 (0.8%) when catheters advanced without difficulty (p=0.014).

DISCUSSION: The inability to advance epidural catheters after the epidural space is identified is a frustrating predicament for obstetric anesthesiologists. We found its incidence when using an Arrow FlexTip Plus® catheter was 4.5%, and it occurred despite high levels of confidence in obtaining loss of resistance. Injecting saline, rotating the needle bevel, and changing the needle angle may be corrective and appear to have little downside. However, re-engaging the ligament and performing a new placement were the most successful corrective maneuvers. Heightened awareness is needed, as an inability to advance the epidural catheter was associated with a higher rate of inadvertent dural puncture.


1. Banwell BR et al. Can J Anaesth 1998.

2. Goyal M. Anaesthesia 2001.

3. Spiegel JE et al. Br J Anaesth 2009.

SOAP 2013