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Tug of War on L&D suite: Winner Team Catheter
Abstract Number: S2C-4
Abstract Type: Case Report/Case Series
While complications are associated with placement and dosing of neuraxial epidural catheter techniques for labor analgesia, removal is considered a benign process. We present the case of an epidural catheter that snapped upon removal after successful placement without complication.
A G3P1 parturient (BMI 25.4) w/o significant PMH at 393/7 weeks had an uneventful labor epidural catheter (Arrow-FlexPlus) placed in the sitting position at L3-L4 as part of a CSE technique. With LOR to saline at 6cm the catheter was secured at 10 cms to the skin. Following a 7 hour labor with good analgesia, she had an uneventful vaginal delivery. Attempted removal in the sitting position an hour post-partum by L&D nurse resulted in a snapped catheter. On examination the catheter was noted to be intact to the 8cm mark with the distal portion stretched, metal coil unraveled and the polyurethane peeled off (Fig 1A). No portion of the catheter was palpable at the skin surface. The patient was informed and denied any immediate neurological symptoms. CT revealed remaining catheter segment in the dorsal aspect of the L3-L4 canal with a portion in the interspinous ligament (Fig 1B). Neurosurgery consult recommended no surgical intervention as the patient was asymptomatic. CT also revealed an incidental liver mass, but abdominal MRI was deemed unsafe due potential for torque and heating of the catheter fragment. The patient was discharged from the hospital on post-partum day 3 and is asymptomatic to this date.
Optimal catheter removal techniques include using slow continuous force with discontinuation if catheter stretches and re-applying traction several hours later, removal in the same position as insertion, attempting removal after injecting PF saline through catheter, and CT for entrapment etiology. Breakage of epidural catheters upon removal is a rare complication that presents a unique set of challenges. Recommendations include CT imaging, neurosurgery consult, counseling of the patient for ‘red flags’ including paresthesia, numbness, fever, motor weakness, discharge or increasing tenderness from insertion site or breach in skin with extrusion of catheter. Surgical intervention is indicated only if the patient is symptomatic and/or if the catheter is exteriorized at the skin.1 It is best to contact the manufacturer for recommendation of MRI compatibility as metal-reinforced catheters can be MRI conditional but not compatible.
1.Journal of Clinical Anesthesia (2007) 19, 310–314