Epidural catheter kinking - An appalling experience.

Abstract

Dear Editor, Epidural anesthesia (EA) forms the backbone of regional anesthesia (RA) techniques. Catheters threaded into the epidural space offer an undisputed advantage in orthopedic surgeries where patients are old and frail, thereby avoiding the adverse effects of general anesthesia (GA). Here, we like to report a case where epidural catheter (EC) kinking was associated with significant perioperative problems, which could have been mitigated with careful planning and vigilance. A 44-year-old male smoker, weighing 90 kg, presented with a fracture of right femur shaft, for which intramedullary nailing was planned. On clinical examination, he was diagnosed with coronary artery disease. Two-dimensional echocardiography was done, which showed regional wall motion abnormality in lateral and inferior walls, with an ejection fraction of 25%–30%.Combined spinal and epidural RA was administered. After attaining adequate anesthesia level, surgical positioning was made and the procedure commenced. Roughly 2 h after surgery, the patient complained of pain. Owing to regression of anesthesia level, local anesthetic (LA) was administered into the epidural space. Unfortunately, a great deal of resistance prevented the LA from being administered. The EC filter was detached, but no obstruction or blockage was felt at this level; nevertheless, the external part of EC could not be evaluated due to the patient’s position. Subsequently, the patient suffered hypertension, tachycardia, and trouble breathing due to severe sympathetic activation. Bilateral crepitations were detected on auscultation, and pulmonary edema was suspected. Labetalol 20 mg, furosemide 20 mg, and morphine 9 mg were administered along with GA. After completion of surgery, patient was turned, and we found that the EC was blocked at the point of its emergence from the skin. Later, the EC was straightened, refixed, LA was injected successfully [Figure 1], and 48-h postoperative pain was altogether treated with epidural infusion.Figure 1: Epidural Catheter KinkingAfter functioning well in the initial period, EC kinking and knot formation may occur at any point between the skin and the epidural space.[1,2] Only few reported its kinking in the subcutaneous tissue or dermis after initial successful functioning, as seen in the indexed case.[3–5] Scawn and Pennefather[4] described a two-stitch technique to secure EC firmly at the skin. However, EC blockage occurred twice, and the authors assumed that the EC was secured too tightly at the dermis, and thus, when the patient was moved for final surgical positioning, the catheter tip could have been slightly withdrawn from the epidural space. But this movement was not transmitted beyond the dermis, causing EC kinking in the compliant subcutaneous tissue. Routine lifestyles often draw EC up to 2.5 cm with body movement. Furthermore, the transition from flexed to deflexed lateral decubitus position causes some degree of skin movement with respect to the epidural space.[5] Non-kinkable reinforced catheters, epidural fixation devices, and rolled gauge bandages between the skin and catheter can minimize EC kinking and migration upon skin emergence. In obese patients or those with the need for long-term catheters, catheter tunneling is another viable approach. However, all aforementioned techniques are not foolproof. Hence, after the final surgical positioning, two spot checks, first, a negative aspiration of cerebrospinal fluid/blood and second, 2–3 ml LA injection through EC, should be carried out. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.