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Retained....and ineffective....epidural catheter during labor
Abstract Number: FCC-327
Abstract Type: Case Report Case Series
A 17 y/o healthy laboring primiparous patient was brought urgently to the operating room for unscheduled Cesarean delivery due to recurrent fetal heart rate decelerations. With continuous fetal monitoring and the patient in lateral decubitus position, a combined spinal-epidural was attempted. Upon loss of resistance, no CSF was obtained with the spinal needle, and the epidural catheter was advanced 5 cm into the epidural space. After negative test dose, the catheter was incrementally dosed with a total of 15 mL 2% lidocaine with epinephrine 1:200,000. At this point the fetal heart rate pattern returned to Category 1 and the obstetrician made the decision to allow labor to continue.
Thirty minutes after placement of the epidural, the patient reported profound numbness and weakness in the right leg, and continued to experience painful contractions. Testing with ice showed a dense sensory and motor block from T12 through sacral levels on the right and no appreciable block on the left. The catheter was withdrawn 2 cm and additional dosing with lidocaine failed to result in a bilateral block, so the decision was made to replace the epidural catheter.
However, the epidural catheter was not able to be withdrawn, despite repositioning the patient several times and having her flex and extend her back. Attempts at removal were abandoned when the catheter began to stretch and exhibit thinning of its diameter.
The anesthesia team rejected the idea of placing a second epidural catheter, even at another vertebral level, due to concerns about shearing with the Tuohy needle, or entanglement involving the retained catheter. As the labor had progressed to 8 cm cervical dilation, consideration was given to offering a single shot spinal. This option was discussed with the patient and her mother, who declined. A fentanyl PCA was initiated for control of labor pain, and the patient had an uneventful vaginal delivery.
The epidural catheter was able to be removed easily one hour after delivery, and a kink was noted 7-8 cm from the tip of the catheter. Given the failure to obtain CSF and the unilateral block, the catheter may have exited a foramen with a nerve root despite the lack of reported paresthesia. In this case, the kink may have been created by impingement near the facet joint.
Review of the literature reveals some suggestions for avoiding or managing retained catheter, but this case is unique in that it occurred prior to delivery.