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Cluster of intravascular epidural catheters resulting in numerous near-misses including a patient with achondroplasia and atlantoaxial instability
Abstract Number: FCC-488
Abstract Type: Case Report Case Series
Intravascular (IV) siting of epidural catheters is an insidious and potentially fatal complication during neuraxial labor analgesia.1 Catheter design has improved over time, with various options that impact analgesic spread, paresthesias, kinking, migration and intravascular cannulation.2 Catheter material plays a significant role with wire-reinforced nylon or polyurethane being the most commonly used, both with high melting points that withstand sterilization and body temperature;2 further features are blunt-tip multiport (closed end 3 eyes) or open-tip uniport. In a randomized control trial, the incidence of IV catheterization was 0% with the Arrow FlexTip Plus® Teleflex (open-tip, polyurethane) catheter vs 10.5% with the Duraflex® Portex (blunt-tip, multiport) catheter.2 Polyurethane catheters reduce IV epidural rate compared to nylon catheters from 4.5% to 0.5% (Table).1 Delayed recognition of IV cannulation is another patient safety issue that may occur with multiport catheters; the lateral holes may be sited in different compartments and the epidural injectate my provide analgesia while the distal hole(s) may be intravascular.2
We have experienced an unpreceded and unacceptable high number of IV epidural catheters in a clustered pattern over the last 9 months. We currently use the Portex/Smiths Medical Duraflex® (blunt-tip multiport) in a customized CSE kit. It has been suggested that fluctuating temperatures during shipment may change catheter stiffness, causing these accidental IV effractions, although other explanations have not been excluded. We present here one of the cases where a late recognition of an IV catheter resulted in a near-miss.
41 yo G6P1 54kg 122cm woman with achondroplasia, atlantoaxial instability, Mallampati 4 airway and large tongue presented for repeat cesarean delivery (CD); previous CD had been with low dose spinal bupivacaine 3.75mg, followed by immediate epidural lidocaine 2%.3 For this CD, a CSE with spinal hyperbaric bupivacaine 7.5mg and neuraxial opioids was provided. The epidural catheter was threaded with initial negative aspiration, however at skin closure, prior to injecting an epidural dose for breakthrough pain, aspiration of frank blood was noted. The possibility of a faulty catheter in such complex patient with challenging airway and short stature triggered a thorough investigation of these catheters.
1. Anesth Analg 2009;108:1232-42
2. Anesthesiology 2014;121:9-17
3. J Anesth Clin Res 6:496