Uncoiling of Arrow Flextip plus epidural catheter reinforcing wire during catheter removal: an unusual complication.

Abstract

To the Editor: Unlike most other epidural catheters, the Arrow Flextip epidural catheter (Arrow International, Reading, PA) has a fine stainless-steel wire reinforcement lining the polyvinyl chloride tubing. The wire reinforcement extends to the distal end of the catheter creating a very “soft tip.” The purported advantages of this epidural catheter include a decreased incidence of epidural venous cannulation and paresthesias during insertion (1). While removal of the catheter is almost always uneventful, we present a case in which the epidural catheter reinforcing wire became uncoiled during removal despite the catheter having been placed without difficulty and removed without resistance. A healthy 17-yr-old female patient, weight 68 kg and height 165 cm, presented for repair of a right clubfoot. In the operating room, the patient was positioned in right lateral decubitus on the operating room table. After Betadine skin cleansing and infiltration of local anesthesia, a 17-gauge Tuohy epidural needle was inserted at the L5-S1 interspace. Placement into the epidural space was successful on the first attempt and confirmed by loss of resistance to saline. A 19-gauge Flextip Plus epidural catheter was advanced 4.5 cm into the epidural space without difficulty and the epidural needle withdrawn. After induction of general endotracheal anesthesia, an infusion of local anesthetic and opioid was initiated through the epidural catheter and continued postoperatively. The operation was uneventful and the patient reported excellent analgesia from the epidural infusion, while demonstrating no evidence of paresthesias. On postoperative day 3, epidural analgesia was discontinued. The patient was placed into the left lateral decubitus position and the catheter was removed without difficulty. Once the catheter was outside the patient, however, it was noted that the catheter reinforcing wire had become uncoiled at the distal end and remained inside the patient (Fig. 1). Gentle traction was applied to the wire, and it was successfully withdrawn. The patient encountered no paresthesias during the catheter or wire removal, and she was discharged home later that day without complications. Figure 1.: Photograph of Flextip Plus epidural catheter taken immediately upon catheter removal illustrating uncoiled portion of reinforcing wire remaining inside patient. Note the otherwise intact appearance of the catheter tip.Although it is rare to encounter complications while removing epidural catheters, epidural hematoma, catheter sequestration, and catheter knot tying have all been reported (2–4). Review of the literature reveals only one other case of uncoiling of a reinforcing wire upon removal of an otherwise intact Arrow Flextip epidural catheter (5). However, in that reported case the authors discuss difficulty placing the catheter through the needle on the first attempt and epidural needle repositioning was required. In our case, the catheter was placed without difficulty on the first attempt. Similarly, the epidural catheter was removed without difficulty when uncoiling occurred. The retained reinforcing wire subsequently withdrew easily and appeared intact, and the patient experienced neither radicular symptoms nor paresthesias during catheter or wire removal. We chose not to obtain radiographs in an effort to search for retained wire because the wire withdrew easily and the patient remained asymptomatic. After discussion with neurosurgical colleagues, it was felt that management of the patient would not be altered by the presence of a nonvisible, asymptomatic retained wire. Furthermore, the risk of locating and removing inert wire may have outweighed the risk of leaving it in situ (6). In summary, we present a case in which the reinforcing wire of an otherwise intact epidural catheter became uncoiled during removal. While it is a rare occurrence, anesthesia providers should be aware of this potential complication when using this product, even when placed without difficulty and removed without resistance. The manufacturer has been made aware of this incident. John L. Bastien, MD Morgan G. McCarroll, MD Lucinda L. Everett, MD