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Print version ISSN 0034-7094
Rev. Bras. Anestesiol. vol.58 no.6 Campinas Nov./Dec. 2008
Breakage of a catheter in the epidural space*
Rotura de catéter en el espacio epidural
Cristian Sbardelotto, M.D.I; Mauro Matsumoto Yoshimi, TSA, M.D.II; Raquel da Rocha Pereira, TSA, M.D.III; Renato Almeida Couto de Castro, TSA, M.D.IV
do CET/SBA do Serviço de Anestesiologia de Joinville (SAJ)
IIInstrutor do CET/SBA do SAJ
IIIMédica do SAJ
IVResponsável pelo CET/SBA do SAJ
OBJECTIVES: Breakage of epidural catheters during their removal is rare,
but it has been described. The anesthesiologist should be aware of the complications
and proper handling of those catheters. The objective of this report was to
present a case of breakage of an epidural catheter in labor analgesia.
CASE REPORT: A 33-year old female, gravida II, I delivery, was admitted to the maternity ward in labor. After two hours, the patient requested analgesia. On physical exam, the patient was in labor, with cervical dilation of 5 cm, regular uterine dynamics, broken amniotic membrane, and pain of 10 by the Visual Analog Scale (VAS). Labor analgesia was instituted using combined double puncture technique. During labor evolution, one analgesia complementation through the catheter. Catheter removal was somewhat difficult, leading to breakage of the catheter. Axial CT and X-ray of the lumbar spine did not show the fragment of the catheter. Since the patient was asymptomatic, without signs of radicular irritation, pain, or infection, proper precautions were taken and the patient was discharged from the hospital.
CONCLUSIONS: Epidural catheters in the lumbar region are, occasionally, hard to remove. Factors that increase the chances of knot formation and the risk of breakage of catheters were listed. In the present case, one of the main factors was the excessive introduction of the epidural catheter. Luckily, neurologic complications are even less frequent, and applying gentle traction, in the absence of paresthesias, the catheter is usually successfully removed.
Key Words: ANALGESIA: labor; COMPLICATIONS: epidural catheter, breakage.
Y OBJETIVOS: La rotura del catéter epidural durante su retirada es
rara, pero ya se ha descrito. El conocimiento de las posibles complicaciones
y el manejo adecuado es de total responsabilidad del anestesiólogo. El
objetivo de este relato fue presentar un caso de rotura de catéter epidural
en analgesia de parto.
RELATO DEL CASO: Paciente del sexo femenino, 33 años, GII, PI, entró en la maternidad en trabajo de parto. Después de dos horas de evolución, la paciente solicitó analgesia. Al realizársele el examen, se encontraba en fase activa del trabajo de parto, con dilatación cervical de 5 cm, dinámica uterina regular, bolsa rota, con dolor clasificado por la Escala Visual Analógica - VAS 10. Se inicia la analgesia de parto por la técnica combinada con doble punción. Durante la evolución se hizo una complementación analgésica por catéter. En la retirada hubo una pequeña dificultad y su consiguiente rotura. Se optó entonces por la realización de una tomografía axial computadorizada y una radiografía de la región lumbar que no mostró la presencia del fragmento del catéter. Visto que la paciente evolucionó asintomática y clínicamente, y sin señales de irritación radicular, dolor o infección, se procedió a las debidas orientaciones y a su alta.
CONCLUSIONES: Los catéteres epidurales en la región lumbar son a veces raros, difíciles de retirar. Los factores que pueden aumentar las chances de formación de nudos y el riesgo de rotura del catéter se relacionaron. En ese caso, uno de los principales factores involucrados fue la introducción excesiva del catéter epidural lumbar. Por suerte, las complicaciones neurológicas son todavía más raras y secundando las directrices de una tracción lenta y suave en la falta de parestesias en la mayoría de los casos, el catéter se retira con éxito.
Breakage of epidural catheters during their removal is rare, but it has been described. Reports in the literature describe the occurrence of this complication, emphasizing important topics. Defects on the distal segment of the catheter, due to problems with the manufacturing process or, which is more common, traction of the catheter through the needle while attempting to reposition it, are the main causes of this complication 11. One of the most important factors of this type of complication, and consensus among the authors, is related with the excessive insertion of the catheter in the epidural space 8,11,12.
A 33-year old female from Joinvile, in the state of Santa Catarina, Brazil, ASA I, gravida II, one delivery, was admitted to Maternidade Darcy Vargas in labor. After approximately two hours, the on-call obstetrician requested labor analgesia for the patient. At the moment of the anesthesiologist's evaluation, the patient was in labor, cervical dilation of 5 cm, regular uterine dynamics, membranes were ruptured, and pain classified as 10 by the Visual Analog Scale (VAS). After the technique and possible complications were explained to the patient, she gave her consent, and she underwent labor analgesia by the combined technique. After basic monitoring with electrocardiogram (ECG), no-invasive blood pressure (NIBP), and pulse oximeter (SpO2), the patient was positioned in the sitting position and, after antisepsis of the area, the L3-L4 space was identified and a median puncture was made with a 27G Quincke needle, with reflux of clear cerebrospinal fluid (CSF) in the first attempt, and 5 µg of sufentanil was administered. This was followed by a paramedian puncture in the same intervertebral space with a 17G Tuohy needle; the epidural space was easily identified with the loss of resistance technique. A 16G Portex epidural catheter was inserted, without resistance, until the 3.1-cm mark reached the skin. After 40 minutes, analgesic complementation was requested since the patient complained of pain (VAS 8), uterine dynamics were not mentioned, and the cervix was dilated 5 cm; 4 mL of 0.2% ropivacaine were administered without intercurrences. After 15 minutes, the patient had a pain of 3 on VAS. Labor showed good evolution and, after one hour, the patient was admitted to the delivery room with complete cervical dilation; maternal and fetal intercurrences were not observed during delivery. After the delivery, the patient was placed in the sitting position for catheter removal, which met with resistance. Light traction was applied, the catheter was removed, and the patient did not offer any complaints. The catheter was distended and missing one centimeter of the tip, suggesting rupture of the catheter after traction (Figure 1). The patient was informed of the complication and underwent imaging exams to locate the catheter. X-Rays of the thoracic and lumbar spine, and CT scan of the lumbar spine were requested, but the catheter fragment was not located (Figure 2 and 3). The patient was informed of the results and received orientation about the conservative approach of the case. The patient was asymptomatic when she discharged from the hospital two days later and oriented to follow-up with the Anesthesiology Department of the hospital in case of any future intercurrences. The patient remains asymptomatic one year after the procedure.
Labor analgesia has developed considerably in the last few years, widening the benefits of the mother-fetus binomium. However, the different techniques are still associated with complications, and the anesthesiologist should be able to identify and manage them. There are several reports in the literature on complications of epidural catheters, and among them kinks, loop-formation in the epidural space, knots, breakage, intravascular and intrathecal migration, unilateral blocks, and complete failure of the block due to improper catheter positioning are described 2,12,13.
Epidural catheters have characteristics that the anesthesiologist should know, beginning with the ideal catheter. The ideal catheter should fulfill some criteria: flexibility, stretching capacity, and be disposable. It can be transparent of radiopaque; the first one allows visualization of the drug during administration and to detect the presence of blood in the catheter, while the radiopaque catheter can be seen on imaging exams. One should observe the material the catheter is made of (nylon, biocompatible polyamide, or polyutherane), if it has a device to help the introduction, if the syringe connector is hermetically sealed and resistant to traction, if the tip of the catheter is round to avoid traumatisms, and if it has markings to help positioning, which facilitates regular distribution of the solution administered 9.
Some studies have demonstrated, using experimental models, that epidural catheters have two distinct phases when stretched, an elastic phase that has a coil effect in which stretching decreases with the increase in force, and a non-elastic phase in which stretching does not increase with further pulling; breakages are bound to occur in the second, non-elastic, phase 10. Another study demonstrated, in an in vitro model, the degree of stretching of different brands of epidural catheters and the force applied to each one before rupture, that polyamide and polyurethane catheters can distend up to 300% before rupturing, when compared to synthetic fibers catheters that distend approximately 30% before breaking 11.
Breakage of epidural catheters was associated with poor technique during insertion or removal, besides manufacturing defects. Other factors, such as supraspinal and interspinal ligaments, vertebral arches and processes, lumbar fascia, yellow ligament, and lumbar nerve roots, have been implied as places where the epidural catheter can be trapped in during removal 2,11,13.
Several suggestions have been made in the attempt to prevent breakage of epidural catheters during insertion; avoiding excessive catheter insertion into the epidural space is one of the most important among them. Studies have demonstrated that insertion of approximately 4 to 5 cm would be associated with lower rates of complications 8,15.
Some conducts are suggested in cases of difficult catheter removal: stop efforts for about 15 to 30 minutes to allow tissues to relax; mild traction in different directions and varying degrees of flexion and extension of the spine. Other suggestions include placing a light weight at the end of the catheter for soft and constant traction, introduction of a Tuohy needle to work as a guide and injection of NS to detect possible kink or knot formation 5,16.
The position of the patient during insertion of the catheter is the most important factor to determine the position for catheter removal, although several studies have described that the lateral decubitus is better that the sitting position, since the force of traction would be two and a half times smaller 5,6,16.
When facing breakage of a catheter during removal, the different authors agree that the treatment of small fragments in an asymptomatic patient should be conservative, informing the patient of the complication1. This can be explained by the fact that the fragment is sterile and inert. Studies in cats demonstrated that catheter fragments were surrounded by fibrous tissue after approximately three weeks and remained innocuous in the epidural space 10. But early surgical removal is indicated in symptomatic patients. We found some reports on breakage of subarachnoid catheters; in this case, imaging exams to determine the position of the fragment and neurosurgical consult are necessary for early surgical removal, even in asymptomatic patients, due to the unknown risk of complications secondary to a foreign body inside the subarachnoid space, with a potential risk of severe neurologic complications 3,10,14.
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16. Morris GN, Warren BB, Hanson EW et al. - Influence of patient position on withdrawal forces during removal of lumbar extradural catheters. Anesthesiology, 1997;86:778-784. [ Links ]
Correspondence to: Submitted em 8
de maio de 2008 *
Received from Maternidade Darcy Vargas, Joinville, SC
Dr. Cristian Sbardelotto
Rua Urussanga, 800/405, bl. A - Bucarein
89202-400 Joinville, SC
Accepted para publicação em 25 de agosto de 2008
Submitted em 8
de maio de 2008
* Received from Maternidade Darcy Vargas, Joinville, SC