Missing Catheter Tip: The Ghost Fragment.

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To the Editor Catheters are frequently used to administer local anesthetics and opioids to provide postoperative pain relief. Before placement for epidural, intrathecal or peripheral nerve block insertion, it is a routine practice to check the integrity of the catheter, filter, and Luer lock. Connecting the individual components and ensuring resistance-free administration of saline through the assembly confirm its proper functioning and also rule out any manufacturing defect. During removal, the tip of catheter is inspected to ensure its complete retrieval. In a recent study, catheter breakage that leaves a catheter fragment in situ scored high among adverse events associated with thoracic epidural analgesia.1 The intact catheter tip is tapered, rounded, closed, and usually blue or black in color depending on the manufacturer (Figure). In a broken catheter, the colored tip is missing and the end is open. Breakage may be due to either catheter shearing during its placement or undue force applied during its removal. Adopting proper technique for catheter placement minimizes the chance of its shearing. Inserting at proper depth and avoiding excessive force when inserting the catheter minimize the chance of knotting and entrapment and make its removal easier. Additional measures have been suggested when difficulty is encountered during catheter removal.2Figure.: A, Catheter having colored and blunt tip. B, Cather without colored tip and having a sharp edge.If the colored tip is missing despite smooth placement and easy removal, it is reasonable to assume that it may still be inside the body. This situation becomes even more likely when technical difficulties are encountered during catheter placement or removal. In either case, the presence of a residual catheter fragment is confirmed by imaging and a decision must be made whether to retrieve it or leave it in situ.2 In the former case, the patient is subjected to an additional procedure; in the latter case, the patient may suffer psychologically. The same holds true for the anesthesia team as well. Just such an incident occurred at our institution, it was associated with a change in the make of the epidural catheter for peripheral nerve block. The tip of the new catheters (Contiplex D, B Braun) is not colored. Instead, a color mark is present just proximal to the tip. It also has a sharp edge with open end (Figure). The combined features initially gave us the impression that the tip was broken and retained inside the body. Neither the name of the catheter nor a description of its tip was included in the anesthesia record. We avoided unnecessary investigations to find the nonexisting fragment, termed the ghost fragment, by counting the number of segments and correlating them with the markings on the catheter. This was further confirmed by inspecting another catheter of the same make. The incident highlights that every time a catheter is used, each component of the catheter set should be carefully inspected for variations. It also raises the need for common standards among manufacturers of catheters. Although manufacturers are bound by federal law to report adverse events related to fracture of anesthetic conduction catheters or device-related malfunctions within 30 days, health care reporters are also encouraged to do so.3 ACKNOWLEDGMENT Dr. Pradeep Bhatia, Professor and Head, Department of Anaesthesia and Critical Care, AIIMS, Jodhpur. Bharat Paliwal, MDAssistant Professor Anesthesiology[email protected] Priyanka Sethi, MDSenior Resident Anesthesiology[email protected] Kamal Kishore, MDAdditional Professor Anesthesiology[email protected] Anamika Purohit, MSJunior Specialist Obstetrics and Gynaecology[email protected]