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Print version ISSN 0034-7094
On-line version ISSN 1806-907X
Rev. Bras. Anestesiol. vol.58 no.3 Campinas May/June 2008
Rotura de catéteres epidurales: etiología, prevención y conducta
Adriano Bechara de Souza Hobaika, TSA
Anestesiologista da Santa Casa de Belo Horizonte e do Hospital SOCOR; Co-Responsável pelo CET/SBA Santa Casa de Belo Horizonte
OBJECTIVES: The objective of this study was to review published cases of
breakage of epidural catheters and, with the data gathered in the literature,
to identify predisposing factors for catheter breakage, and list the recommended
conducts to prevent and treat this complication.
METHODS: The search included the data banks of Pubmed, Embase, and SciELO.
RESULTS: A total of fifteen studies reporting 30 cases of breakage of epidural catheters were identified. Information regarding the catheterization and removal of the catheter, besides the type of catheter, were analyzed for each case. Complications related to the presence of retained catheter fragments, as well as the indications for exploratory laminectomy, were recorded. With the evidence gathered from the literature, recommendations for prophylaxis and treatment of this complication were elaborated.
CONCLUSIONS: The catheter should not be inserted more than five centimeters into de epidural space. Exploratory laminectomy should be undertaken if the patient develops signs or symptoms of neurologic changes, if the catheter is inside the subarachnoid space, or whenever the tip of the catheter is emerging out of the skin. Due to the difficulty to localize retained fragments by imaging exams, catheters should be manufactured with materials that improve their visualization.
Key Words: ANESTHETIC TECHNIQUES, Regional: continuous epidural; COMPLICATIONS: epidural catheter.
Y OBJETIVOS: El objetivo de este estudio fue revisar los casos publicados
de rotura de catéter epidural. Con las evidencias recolectadas en la
literatura, identificar los factores que predispusieron la rotura y relacionar
las conductas recomendadas para la prevención y el tratamiento de esa
MÉTODO: Se realizó una investigación de la base de datos de la Pubmed, Embase y SciELO.
RESULTADOS: Un total de quince artículos se identificó, relatando 30 casos de rotura de catéter epidural. Los casos se evaluaron en cuanto a las informaciones referentes a la cateterización y a la retirada, además del tipo de catéter. Se registraron las complicaciones provocadas por la presencia de los fragmentos que quedaron dentro de los pacientes, además de las indicaciones para la realización de la laminectomía exploradora. Con las evidencias obtenidas en la literatura, se elaboraron recomendaciones referentes a la profilaxis y al tratamiento de esta complicación.
CONCLUSIONES: La introducción del catéter no debe ser hecha en un espacio superior a cinco centímetros en la región epidural. Se debe proceder a la laminectomía exploradora si el paciente presenta señales o síntomas de alteraciones neurológicas, si el catéter está localizado dentro del espacio subaracnoideo o cuando la punta rota del catéter está surgiendo por la piel. Debido a la dificultad en ubicar los fragmentos retenidos con los exámenes de imagen de que disponemos, los catéteres deberían ser fabricados con materiales que facilitasen su visualización.
Since the epidural catheter was introduced in anesthesiology by Curbelo, it has become an important component of the anesthetic armamentarium. It allows regularization of surgical blocks, labor and postoperative analgesia, and relief of oncologic pain. Contra-indications of catheterization are, in theory, the same for neuro-axis block: infection at the puncture site, clotting disorders, and refusal by the patient. Among the complications, one can mention: abscess, spinal hematoma, radiculopathy, knot or breakage of the catheter. Some reports reviewed the occurrence of abscesses 1, while others have established standards for epidural catheterization in anticoagulated patients 2. However, the circumstances involved in epidural catheter breakage have not been reviewed.
The objective of this report was to review the cases of epidural catheter breakage published in the literature and, with the evidence gathered, identify predisposing factors for said breakage, and list the recommended conducts for prevention and treatment of this complication.
A search of the Pubmed and Embase data bank using the words epidural/peridural catheter breakage and epidural/peridural catheter fracture, and of the SciELO data bank using the words quebra cateter peridural/epidural (breakage catheter epidural), fratura cateter peridural/epidural (fracture catheter peridural/epidural) was undertaken. All articles on breakage of epidural catheters were selected and evaluated regarding information on insertion and removal, and the type of catheter were evaluated. Complications related to the presence of retained fragments, and the need of exploratory laminectomy, were also recorded. Based on the information obtained, evidence-based recommendations were elaborated.
For the period between 1957 and the present date, fifteen articles reporting 30 cases of epidural catheter breakage were identified 3-17. Chart I shows the cases in chronological order and the most important data.
Epidural catheter breakage is a rare occurrence, with only isolated reports. Events involved with this complication have not been studied systematically.
Regarding the puncture site, all cases reported used the spaces between L2 and L5, probably because the frequency of lumbar epidural is much greater than thoracic or cervical.
One can affirm that, in most cases, the catheter broke during a difficult removal, with increased resistance. Resistance during removal might occur due to coiling of the catheter, a knot of the catheter, or entrapment of the catheter by the supraspinous or interspinous ligaments. Vertebral arches and processes, the lumbar fascia, the yellow ligament, posterior vertebral joints, and lumbar nerve roots have been implicated as sites of catheter entrapment 12.
Removal of the catheter by the anesthesiologist or trained personnel is the conduct recommended in the literature for cases of difficult catheter removal. This is justified because, in two cases, the catheter broke when non-trained personnel removed the catheter: in the case of Nishio et al. 11, the catheter broke when an orthopedist tried to remove the catheter with a hemostatic forceps and, in the case of Demiraran et al. 16, the catheter broke during removal by a non-trained individual who did not identify the complication and the diagnosis of catheter breakage was done four days later. This is an alert that epidural catheters should be removed only by individuals trained for the task. Removal should be done cautiously, applying continuous force, avoiding the use of excessive force. Prehension devices, such as hemostatic forceps, should never be used 11. The patient should be positioned in lateral decubitus for an easier removal 5,18. When facing a difficult catheter removal one can inject normal saline through the catheter before another attempt 19,20. Some authors recommend waiting thirty to sixty minutes before another attempt. Although this conduct lacks a logical explanation, it was effective in two cases of difficult catheter removal 10,21. The patient should not experience pain during the removal of a catheter; in case of pain, the anesthesiologist should assume that it might be tangled around a nerve root. Due to the possibility of nerve root avulsion, the catheter should be removed under direct visualization through a laminectomy 18. When it is impossible to remove the catheter, one should consider the presence of a knot in the catheter and proceed with imaging exams.
In one case of a difficult catheter removal, a sterile Tuohy needle was introduced in the epidural space using the catheter as a guide; the needle and the catheter were removed as one set. Although this method was successful in the case described, it has a clear risk of catheter breakage and, therefore, this technique is not recommended 22.
Although in most cases the catheter breaks when there is great resistance for its removal, other risk factors at the moment of introduction could be identified. Manufacturing defects had been described in the past, when the device was first introduced in anesthetic practice and, therefore, the catheter and needle should be carefully inspected to identify any defects before the puncture 4,23. One should never pull the catheter when it is inside the needle because the tip of the needle can cut it off. Never suture the catheter to the skin because it can predispose it to rupture 13. It should never be inserted more than 5 cm in the epidural space because it increases the risk of knots or coiling around a nerve root 11,24. The data suggest that the introduction of a greater length of the catheter increases the possibility of failure in case of a laminectomy in one case in which 15 cm of the catheter was introduced, the laminectomy failed to remove the fragment 17.
To elucidate the possible causes of catheter breakage related to the manufacturing process, some researchers evaluated the characteristics inherent to the materials and to the epidural catheters that could predispose their breakage. The tensile strength of those materials was evaluated, and they concluded that nylon or polyurethane catheters were more resistant than Teflon or polyethylene catheters 11. Ates et al. 23 concluded that polyurethane catheters were more resistant than radiopaque catheters. Reinforced 20G catheters seem safer than 19G catheters because they have a tendency to break at the site of traction, while 19G catheters have a tendency to break at a fixed site near the tip 25. As for catheters reinforced with steel coils, they seem to have a greater tendency to break than non-reinforced catheters 10. In the case in which 12 catheters broke and there was a reference to the type of catheter used, five were 19G Arrow Flextip® type, which is reinforced and manufactured with polyurethane, and four were nylon Portex® type. Thus, as for the materials used to manufacture those catheters, there is a conflict among laboratory tests results and between laboratory tests results and clinical evidence.
Despite the recommendation of conservative treatment for catheter breakage, of 25 asymptomatic cases, 11 (44%) underwent exploratory surgery, even when it was not indicated, and in three of them (27%) it was impossible to remove the fragment 3,14,17. In one case, the fragment was removed upon request by the patient, even though he was asymptomatic 11. Three out of the five cases in which surgical removal was indicated underwent successful laminectomy 7,8,16, while the other two, despite persistent symptoms, the procedure was not performed and the patients developed definitive sequelae radicular compression syndrome 9. The symptoms of radicular compression syndrome include, usually, severe lumbar pain irradiating to the buttocks and lower limbs, and paresthesias in the dermatome corresponding to the nerve root involved. Cases with definitive sequelae were rare, even in the presence of retained fragment 9.
In some cases, the catheter might break up and the broken tip slides out of the skin, representing a potential entry site for infection of the epidural space, which is an indication for exploratory laminectomy. In one such case, the catheter was coiled around the yellow ligament (10 cm), which did not allow its removal, and a successful exploratory laminectomy was performed 24.
Therefore, in view of the evidence quoted, one can suggest a few conducts in case of catheter breakage. The neurologist should always evaluate the patient and the presence of neurologic deficits should be determined. Imaging exams should be done in all cases to determine the exact location of the fragment. This documentation can be very important for the clinical follow-up of asymptomatic patients, and to orient laminectomy in symptomatic patients. It is noteworthy that, in many cases, even radiopaque catheters could not be visualized in an X-ray of the spine, especially when they are located in the epidural space 4,9,10,12,17. Thus, visualization of the fragment was accomplished by other imaging exams: MRI, CT, and lumbar ultrasound. Recently, the ultrasound has been used successfully to locate fragments not seen in X-rays. Retained fragments of an epidural catheter usually do not cause symptoms, and most authors do not recommend their removal. Exploratory laminectomy should be done if the patient develops neurologic changes 3, or if the catheter is in the subarachnoid space 12. Exploratory laminectomy to remove the catheter is also indicated when the broken catheter cannot be removed and its tip is emerging out of the skin, because an entry site for infection of the epidural space has been created. However, even after being informed of the prognosis, the patient might refuse removal of the retained fragment. Due to the rare complications that might develop secondary to the presence of a retained fragment, the patient should be informed of this intercurrence and monitored periodically by his clinician. Cases of radicular compression syndrome, foreign body reaction, and lumbar stenosis have been reported and attributed to the retained fragment 7-9.
Catheterization of the epidural space is an acclaimed technique in Anesthesiology, and cases of catheter breakage are rare. The catheter should not be introduced more than 5 cm into the epidural space. Exploratory laminectomy should be undertaken if the patient develops neurological changes, the catheter is in the subarachnoid space, of when its tip is emerging out of the skin. Due to the difficulty to localize retained fragments with the available imaging exams, catheters should be manufactured with materials that are more easily visualized.
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11. Nishio I, Sekiguchi M, Aoyama Y et al. Decreased tensile strength of an epidural catheter during its removal by grasping with a hemostat. Anesth Analg, 2001;93:210-212. [ Links ]
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24. Blass NH, Roberts RB, Wiley JK The case of the errant epidural catheter. Anesthesiology, 1981;54:419-421. [ Links ]
25. Tsui BCH, Finucane B Tensile strength of 19- and 20-gauge arrow epidural catheters. Anesth Analg, 2003;97:1524-1526. [ Links ]
Correspondence to: Submitted em 25
de maio de 2007 * Received from
Santa Casa de Belo Horizonte, Belo Horizonte, MG
Dr. Adriano Bechara de Souza Hobaika
Rua Des. Jorge Fontana, 214/1.601 Belvedere
30320-670 Belo Horizonte, MG
Accepted para publicação em 19 de fevereiro de 2008
Submitted em 25
de maio de 2007
* Received from Santa Casa de Belo Horizonte, Belo Horizonte, MG