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Intrathecal Catheter Management Outcomes-a review of 5 years of practice at Columbia University Medical Center
Abstract Number: S-02
Abstract Type: Original Research
Inserting an epidural catheter into the intrathecal (IT) space after inadvertent dural puncture (IADP) avoids another IADP and may reduce the risk of postdural puncture headache (PDPH) and need for epidural blood patch (EBP). Clinicians have worried about the risk of neurologic injury, inadvertent drug overdose, failed block, and infection. There are few reports of outcomes with IT catheters in parturients.
Methods: A retrospective chart review was performed for patients with IT catheters from 2/09–11/13.
Results: We identified 58 IT catheters; 4 were not initially recognized. Smiths Medical Portex® Combined spinal/epidural (CSE) kits (Smiths Medical, Keene, NH, USA) (17G Tuohy/19G Duraflex® epidural catheter, closed end, 3 eyes) were used. Mean (SD) age and BMI were 31 (5.8) yrs and 31.4 (7.3) kg/m2. Mean loss of resistance (LOR) to saline was 4.5 (0.9) cm, with insertion to 3.2 (2.2) cm. Of 46 placed for labor analgesia, only 1 was intentional. In the OR, 11 were placed during attempted CSE for cesarean section (CS) and 1 during attempted CSE for external cephalic version. There were no assisted vaginal deliveries and 14 laboring patients delivered by CS.
Labor analgesia was typically initiated with 0.25% bupivacaine (0.5 – 1 ml) and fentanyl 10 -20 μg. Maintenance was with bupivacaine 0.0625% with fentanyl 2 μg/ml at 1-3 cc/hr, with no patient-administered boluses in 44 cases; 2 patients had no infusion. No failures occurred for labor analgesia. No top-up doses were required in 14 patients; 32 got 1 – 6 top-up doses.
For surgical anesthesia, hyperbaric 0.75% bupivacaine (9-12.5 mg) in divided doses was used in most cases. No high blocks occurred. Total 20.6 mg isobaric bupivacaine 0.5% was required in 1 case. Failures occurred in 2/11 catheters placed in the OR. Among catheters used for labor, 1/14 failed for CS and 1 for postpartum tubal ligation.
Catheters were in situ 0.5 – 29.1 hrs postpartum. Saline was injected in 33 cases (usually 10-15 ml) during use or removal. Saline 2ml/hr for 20 hrs postpartum was given in 1 case. That patient did not have EBP and reported a 5/10 PDPH.
EBP was performed in 23 (40%) cases, in 2 prior to any complaints of PDPH, and in 6 after discharge. In 4 cases, 2 EBPs were needed. The PDPH rate was 66%, with 33% rating their pain as severe (score ≥ 7/10). There was no effect on the incidence of PDPH or EBP related to BMI, time of placement, duration of insertion, volume of saline injected, or mode of delivery.
A patient with an unrecognized IT catheter had a high block after bolus during labor. Postpartum, 2 catheters were found disconnected at the hub, with CSF leakage.
Conclusion: Our review indicates IT catheters are safe and effective for labor analgesia, with no failures or replacements needed. Only 1/14 failed for CS (comparable to our 8% epidural catheter failure rate). It is intriguing that 2/11 catheters placed for CS failed, but the sample size is too small for conclusions to be drawn.