Use Of Epidural Catheter Research Articles

Intercostal nerve cryoablation as part of an opioid-sparing protocol reduces opioid and epidural use after lung transplant

IntroductionInadequate pain control after lung transplantation increases perioperative complications. Standard opioid-based regimens are associated with adverse effects and epidural catheters that reduce opioid use are limited by contraindications and technical challenges. We report the use of intercostal nerve cryoablation to enhance perioperative pain control as part of an opioid-sparing protocol for lung transplant recipients (LTR). MethodsWe conducted a retrospective cohort study of LTRs from 1/1/2016-12/31/2021, before (pre-cryo) and after (post-cryo) initiation of an opioid-sparing protocol utilizing intraoperative intercostal nerve cryoablation. The pre-cryo cohort included consecutive patients treated with opioids and selective use of epidural catheters. The post-cryo cohort received intercostal nerve cryoablation at levels 3-7, scheduled acetaminophen, gabapentin, and tramadol. Additional opioids or epidural catheters were used for breakthrough pain. ResultsIn total, 49 pre-cryo and 40 post-cryo patients were analyzed. Baseline demographics were similar aside from a shift to performing more bilateral lung transplants in the post-cryo cohort (57% vs 95%, p<0.0001). Total opioid usage during the index hospitalization decreased by 24% (1110 vs 841 morphine milligram equivalents [MME], p=0.027), and 28% in the bilateral LTR subgroup analysis (1168 vs 846 MME, p=0.007). Epidural use declined from 61% to 3% (p<0.0001). Median opioids prescribed at discharge decreased by 66% (450 vs 154 MME, p<0.0001). ConclusionsThe implementation of a perioperative pain management protocol that included intercostal nerve cryoablation was associated with a significant reduction in epidural utilization and opioid use during index hospitalization and upon discharge. Further research is needed to understand the impact on outcomes.

A retrospective cohort study of the anesthetic management of postpartum tubal ligation

BackgroundNeuraxial anesthesia with reactivation of a labor epidural catheter is commonly utilized for postpartum tubal ligations (PPTL), although the optimal anesthetic approach is unknown. We assessed institutional anesthesia practices for PPTL, and evaluated the failure rates of reactivation of labor epidural catheters, de novo spinal anesthesia, and spinal anesthesia after failed blocks. MethodsWe conducted a single-center retrospective cohort analysis of 300 consecutive patients who underwent a PPTL and 100 having spinal anesthesia for cesarean delivery. Anesthetic management data (existing labor epidural catheter reactivation, de novo spinal anesthesia or general anesthesia) were collected from electronic medical records. Anesthetic block failure rates were determined for each anesthetic technique. ResultsThe failure rate was 15% for de novo spinal anesthesia and 23% after failed reactivation of a labor epidural catheter or spinal anesthesia. The epidural catheter reactivation failure rate was 35%. The failure rate of spinal anesthesia for cesarean delivery was 4%. Drug dosage, epidural catheter use in labor, time since epidural catheter placement or delivery, labor neuraxial technique (combined spinal-epidural, epidural), supplemental top-up doses during labor, and anesthesiologist experience did not predict neuraxial anesthesia failures. ConclusionsOur analysis revealed an unexpectedly high neuraxial anesthesia failure rate even when de novo spinal anesthesia was used for PPTL. The results are consistent with other institutions' recent findings, and are higher than spinal anesthesia failure rates associated with cesarean delivery. Further studies are required to determine optimal anesthesia dosing strategies, and to understand the mechanisms behind high neuraxial anesthesia failures for PPTL.

Measurements of Epidural Space Depth Using Pre-Existing CT-Scan Correlate with Loss of Resistance Depth during Lumber Epidural Catheter Placement

Background: The use of epidural catheters provides the best quality intra- and post-operative pain relief for various major thoraco-abdominal and lower limb surgeries. The process of placing an epidural catheter into the epidural space between the vertebrae can be challenging due to variations in spinal anatomy of different level, narrow intervertebral spaces and can cause catastrophic neurological complications. Though various studies have been shown to overcome the placement of epidural catheter using standard ultrasound method, using the pre-existing computer tomography depth correlate with loss of resistance in placing the epidural catheter would be a well adjunct tool for the procedure. Objectives: To correlate measurements taken from pre-existing computed tomography (CT) imaging to the loss of resistance depth as recorded during epidural placement. Methods: This Single procedural observational study was performed in Combined Military Hospital (CMH), Dhaka from 1st December 2018 to 30th November 2019. Fifty adult patients scheduled for lower abdominal and lower limb surgery under epidural anaesthesia (EA). The patient’s advised/routine abdominal CT film was inspected by a radiologist, who was blinded to the results of the actual needle length, to determine the distance from the skin to the ligamentum flava the corresponding level of L2 to L5 interspinous spaces. The distance on the CT film in the midline was measured using a ruler against the measurement scale, conventionally represented as a 5 cm-10 cm scale with 1-cm divisions. The CT-derived depth was calculated using the principle of Pythagorean triangle trigonometry. Result: In this study, Sixty eight percentages of patients (68%) Epidural- skin distance (ESD) had 4.7-6.8cm. Mean Epidural-skin distance 5.8±1.7cm. On evaluation of Loss of Resistance Depth, 46% of patients had 5.2-7.3cm depth of LOR, followed by 30% patients had 3.0-5.1cm and 12% patients had 7.4-9.5cm. Mean loss of resistance depth was 6.3±1.4 cm. It was evident from this study that positive significant correlation (r=0.941; p=0.001) between the CT-derived distance and Loss of Resistance Depth. Conclusion: It is conclude that using pre-existing CT-scan derived distance is helpful in prediction of the epidural space depth and it is correlates with actual loss of resistance epidural needle insertion depth placing the catheter in lumber region.

Pain management with epidural catheter and epidural analgesia after spinal dorsal instrumentation of lumbar spine.

Spinal dorsal instrumentation (SDI) is an established treatment for degenerative spinal diseases. Adequate and immediate postoperative pain control is important for patient recovery and may be compromised by uncertainty about its efficacy and concern about early postoperative surgical complications or adverse events. The aim of the current study was to compare the use of epidural analgesia (EA) with systemic analgesia (SA) as regards pain reduction and early postoperative complications after SDI. Pain management with epidural or systemic analgesia in patients undergoing SDI by posterior approach between January 2019 and July 2020 was evaluated by clinical functional testing, measuring total opioid amounts used, and evaluating numerical rating scale values 24 and 96 hours postoperatively. The following were also monitored: demographic data, number of affected segments, length of hospital stay, inflammatory markers (leukocytes and serum C-reactive protein), early postoperative surgical complication rates, and adverse events. In total 79 patients were included (33 in the EA and 46 in the SA group). The SA group had significantly lower numerical rating scale values at days 1 to 4 after surgery (P ≤ .001) and lower cumulative opioid use than the EA group (P < .001). We found no difference in infection parameters, length of hospital stay or surgery-related complication rates. Our data demonstrate that epidural anesthesia was inferior to an opioid-based SA regime in reducing postoperative pain in patients undergoing spinal surgery. There is no benefit to the use of epidural catheters.

Epidural abscess caused by Serratia marcescens during use of an indwelling tunneled epidural catheter: a case report

Epidural abscess caused by Serratia marcescens during use of an indwelling tunneled epidural catheter: a case report

203. Epidural pain catheter improves postoperative pain control following lumbar fusion compared to patient-controlled analgesia (PCA)

<h3>BACKGROUND CONTEXT</h3> Postoperative pain control for patients in the hospital after lumbar spinal fusion can be quite challenging. Reliance on opioids postoperatively can predispose patients to tolerance and abuse. Multimodal pain control regimens have become the standard of postoperative care, though protocols tend to vary by surgeon and institution. The mainstay of pain control following lumbar spinal fusion surgery involves narcotic pain medication administered by patient controlled intravenous analgesia (PCA), which is typically supplemented by oral pain medications. One potential alternative to PCA is patient-controlled analgesia via epidural catheter. Surgeon-placed epidural catheters under direct visualization have previously been described for their simplicity, efficacy and time efficiency. <h3>PURPOSE</h3> After experiencing clinical success with the use of epidural catheters placed via the loss of resistance technique one- to three- levels above the proximal lumbar fusion level in postoperative care regimens,the senior author (TFA) embarked upon this prospective, randomized trial to assess the relative utility and complication rate of the epidural catheter method of pain management when compared to standard PCA narcotic administration for pain control after one- or two-level circumferential lumbar fusion surgery. <h3>STUDY DESIGN/SETTING</h3> The surgeries in the trial were performed by three surgeons in a university spinal surgery practice. Patients who enrolled agreed to be randomized to either the epidural catheter (EC) or the commonly practiced PCA arm of the study. A power analysis demonstrated that a sample size of 50 patients, using a level of significance of 0.05, would have a power of 0.97 to detect a 2-point difference in pain scores. <h3>PATIENT SAMPLE</h3> Fifty patients from the University spinal surgery practice were recruited to enter the study. Candidates for the study were patients undergoing one- or two-level instrumented lumbar fusion. Patients were randomized over a 10-month period into either the epidural (EA) or IV analgesia (PCA) groups, 27 to EA and 23 to PCA. <h3>OUTCOME MEASURES</h3> Preoperative pain scores, as well as daily postoperative pain scores were recorded. <h3>METHODS</h3> If randomized to the EC arm, an epidural catheter was placed by the surgeon just prior to wound closure, 1-3 levels above the most proximal level of the fusion. A 17-gauge Tuohy epidural needle was used with a loss-of-resistance syringe to locate the epidural space under fluoroscopy if deemed appropriate by the surgeon, and then the catheter was inserted through it. A bolus of 5cc of 0.25% bupivacaine was typically given at the time of catheter placement. Postoperatively, a continuous infusion was begun of 0.125% bupivacaine at 6 cc/hr combined with hydromorphone at 0.2 mg/hr. A patient controlled epidural demand dose of 25mcg of fentanyl with a 10-minute lockout period was also started. If randomized to the PCA group, patients were placed on a patient-controlled analgesia pump administering intravenous hydromorphone with a demand dose of 0.2-0.4 mg with a 10-15-minute lockout <h3>RESULTS</h3> Postoperative pain scores were statistically lower in the EC group on Days 1, 2 and 3: 2.13 vs 4.92 (day 1); 2.71 vs 4.52 (day 2); 3.13 vs 4.52 (day 3). Postoperative complications were similar between the EC and PCA groups. The incidence of nausea/vomiting were 56% and 74% (p=0.43) in EC and PCA groups, respectively, while postoperative symptomatic hypotension was seen in 8% of EC patients and 12% of PCA patients (p=0.67). <h3>CONCLUSIONS</h3> In this prospective, randomized study comparing the use of EC to PCA narcotic for pain control after one- and two-level lumbar fusions, a significant improvement in pain control was noted in the EC group with differences in minor side effects that did not reach statistical significance. Epidural anesthesia for postoperative pain control should be considered for patients undergoing lumbar fusion. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Double epidural catheter technique in a patient with severe COPD undergoing major abdominal surgery: A case report.

Introduction and importanceChronic Obstructive Pulmonary Disease (COPD) leads to the development of postoperative pulmonary complications (PPC), such as atelectasis, pneumonia and respiratory failure.The use of epidural anesthesia, alone or combined with general anesthesia, is known to reduce the incidence of PPC and shorten tracheal intubation time. In major procedures involving both the lower and upper abdomen, central neuraxial block at a single level may be inadequate to provide sufficient metameric extension of anesthesia. This limitation could be overcome with the use of double epidural catheter (DEC), has proved effective in diverse surgical scenarios.Case presentation and clinical discussionWe present the case of a woman affected by moderate-severe COPD scheduled for major abdominal cytoreductive surgery due to ovarian malignancy with planned xypho-pubic laparotomy. We developed and implemented a DEC-based strategy for perioperative pain management based on the extent of surgical incision and the high risk of difficult weaning from ventilation and PPC.We used intraoperative monitoring to guarantee adequate antinociception throughout the entire 350 min long demolitive surgical procedure. No additional top-ups of intravenous analgesia or neuromuscular blocking agent (NMBA) was needed during surgery; at the end of the procedure, the patient was extubated in the operating theatre, maintaining adequate respiratory function during the whole postoperative period.ConclusionsThe DEC technique could be beneficial for patients undergoing cytoreductive surgery. In our case, this technique granted optimal analgesic coverage and was instrumental in achieving fast weaning from mechanical ventilation and early tracheal extubation. Systematic studies on this subject are warranted.

Epidural catheter misplacement and knot formation within the hypoaxial musculature of a dog

AbstractTechnical complications associated with the use of epidural catheters account for a significant proportion of failures of this technique. Misplacement and knotting of epidural catheters are complications rarely described in both human and veterinary literature. The method used to identify and confirm the correct position of the catheter in the epidural space plays an important role in preventing such complications. However, some of the techniques commonly used can still lead to an equivocal catheter placement. We report a case where loss of resistance, positive analgesic effect and motor deficits of both hindlimbs masked a misplaced epidural catheter in a dog, with knotting of the catheter occurring when removal was attempted.

Knowledge and Practice of and Attitude Toward Epidural Analgesia Among Pregnant Women in Jazan Region of Saudi Arabia.

The aim of this study was to assess the knowledge, sources of knowledge, attitudes (fears and misconceptions) toward epidural analgesia (EA), and practices of parturient delivery in the Jazan region of Saudi Arabia. A cross-sectional study was conducted using a self-administered survey questionnaire distributed in the antenatal care clinics of the obstetric departments of major hospitals. A total of 454 women participated in this study. Of the participants, 219 (48%) belonged to the 31 to 40-year age group and 134 (30%) to the 21 to 30-year age group. Most participants (344, 76%) had a bachelor's degree. The prevalence of epidural catheter use was 23.6% among pregnant women. Statistically significant differences in educational level and residence were found between the women (p < 0.001). The two most common sources of information cited by the pregnant women were healthcare staff and family and friends. The most common motive reported by women was to relieve labor pain effectively, and the most frequently cited barriers preventing women from receiving EA were the possibility of injury to important organs and the inability to walk after EA. The present study demonstrates a low level of knowledge about EA among pregnant women in the region. More awareness and guidance about EA are warranted.

Addition of Local Anesthetic Epidural Infusion Catheter to Intravenous Opioid Analgesia for Postoperative Pain Control in Children Undergoing Video Assisted Thoracoscopic Surgery (VATS)

PurposePostoperative analgesia following minimally invasive video assisted thoracoscopic surgery (VATS) in pediatric patients may involve intravenous opioid analgesics and continuous local anesthetic infusions via an epidural infusion catheter. The use of epidural catheters may avoid systemic side effects of intravenous opioids in this vulnerable population. DesignOur primary aim was to compare total morphine equivalents (MEQ) required, and pain scores between local anesthetic epidural infusion catheters combined with intravenous opioids, versus intravenous opioids alone in pediatric patients following VATS procedure. MethodsFollowing Institutional Review Board approval, we performed a retrospective chart review of children (ages 1 month to 18 years) who underwent VATS procedure for noncardiac thoracic surgery. Based on the postoperative analgesic technique used, the study population was divided into two groups that is, epidural group and nonepidural group. Both groups received intravenous systemic opioids. The primary outcome variables were total MEQ required and pain scores in the perioperative period. FindingsNinety-two patients were included in the study. Of these, 22 patients belonged to the epidural group versus 70 patients to the nonepidural group. There was no statistical difference in MEQ requirements or pain scores between the groups intraoperatively (P = .304), in the postanesthesia care unit (P = .166), or at postoperative time intervals of 24 hours (P = .805) and 48 hours (P = .844). The presence of infection or empyema was a significant factor for the avoidance of epidural placement by providers (P = .003). ConclusionsThere was no significant difference in the perioperative MEQ or postoperative pain scores between the epidural catheter group and the nonepidural group. More research is necessary to determine if this could be due to epidural catheter malposition and/or inadequate dermatomal coverage of surgical chest tubes.

Intercostal Nerve Cryoablation as Part of an Opioid-Sparing Protocol Reduces Narcotic and Epidural Use After Lung Transplant

<h3>Purpose</h3> Inadequate pain control increases perioperative complications yet narcotic-based analgesia is associated with serious side effects. Epidural catheters can reduce narcotic use but contraindications and technical challenges are common. We report on the use of intercostal nerve cryoablation as part of an opioid-sparing perioperative pain control protocol. <h3>Methods</h3> We reviewed adult lung transplants from 10/2017-8/2021 to compare practices before (pre-cryo) and after (post-cryo) the protocol. The pre-cryo cohort included consecutive patients treated with narcotics and selective use of epidural catheters. The post-cryo cohort received cryoablation at levels 3-7, scheduled acetaminophen, gabapentin, and tramadol. Stronger narcotics or epidurals were used for breakthrough pain. Patients were excluded for intubation >48 hours, reintubation, or <8 week follow-up. Morphine milligram equivalents (MME) were collected and analyzed at several time points. Outpatient use was estimated by prescriptions written within 8 weeks of transplant. <h3>Results</h3> A total of 34 pre-cryo and 30 post-cryo patients were analyzed. Baseline demographics were similar aside from a significantly older post-cryo cohort (61 vs 56 years, p=0.043). Total inpatient and outpatient narcotic use decreased by 32% (figure). In addition, epidural use declined from 53% to 3% (p<0.001). These decreases occurred even though the post-cryo cohort included significantly more bilateral lung transplants (93% vs 56%, p=0.001). Post-cryo patients were prescribed significantly less narcotics at discharge (p<0.001) but received similar post-discharge outpatient prescriptions. <h3>Conclusion</h3> The implementation of a perioperative pain protocol that includes intercostal nerve cryoablation was associated with a significant reduction in epidural utilization and total opioid consumption in the first 8 weeks post-transplant. Further research is needed to delineate the impact on clinical outcomes.

Pneumorrhachis complicating acute pain management using a thoracic epidural catheter

The use of thoracic epidural catheters to infuse local anaesthetics and opioids is a common practice in acute pain management to attenuate the pain associated with thoracic and abdominal surgical procedures. The placement and maintenance of epidural analgesia is known to be associated with a variety of potential complications. A rare complication is the development of air of within the spinal canal (pneumorrhachis). Although pneumorrhachis is typically asymptomatic and resolves spontaneously, it rarely can be associated with neurological dysfunction. Here we describea case of pneumorrhachis that led to symptomatic acute spinal cord compression in a 27 year old man who had a thoracic epidural placed to help with pain management following laparotomy for the management of Crohn’sdisease. Postoperatively, the patient developed unilateral weakness in his upper and lower extremities and sensory dysfunction in the upper extremity. Urgent neuroimaging demonstrated epidural air causing mass effect on the cervical spinal cord. His symptoms resolved completely following conservative management. This rare presentation of pneumorrhachis highlights the need for close vigilance regarding neurological function in patients with epidural catheters for acute pain management. This presentation also promotes mitigation of factors that may be associated withthe administration of air into the epidural space, such as changing epidural infusion solution bags and malfunction of epidural infusion pumps.

Intercostal liposomal bupivacaine injection for rib fractures: A prospective randomized controlled trial.

Blunt chest wall injury accounts for 15% of trauma admissions. Previous studies have shown that the number of rib fractures predicts inpatient opioid requirements, raising concerns for pharmacologic consequences, including hypotension, delirium, and opioid dependence. We hypothesized that intercostal injection of liposomal bupivacaine would reduce analgesia needs and improve spirometry metrics in trauma patients with rib fractures. A prospective, double-blinded, randomized placebo-control study was conducted at a Level I trauma center as a Food and Drug Administration investigational new drug study. Enrollment criteria included patients 18 years or older admitted to the intensive care unit with blunt chest wall trauma who could not achieve greater than 50% goal inspiratory capacity. Patients were randomized to liposomal bupivacaine or saline injections in up to six intercostal spaces. Primary outcome was to examine pain scores and breakthrough pain medications for 96-hour duration. The secondary endpoint was to evaluate the effects of analgesia on pulmonary physiology. One hundred patients were enrolled, 50 per cohort, with similar demographics (Injury Severity Score, 17.9 bupivacaine 17.6 control) and comorbidities. Enrolled patients had a mean age of 60.5 years, and 47% were female. Rib fracture number, distribution, and targets for injection were similar between groups. While both groups displayed a decrease in opioid use over time, there was no change in mean daily pain scores. The bupivacaine group achieved higher incentive spirometry volumes over Days 1 and 2 (1095 mL, 1063 mL bupivacaine vs. 900 mL, 866 mL control). Hospital and intensive care unit lengths of stay were similar and there were no differences in postinjection pneumonia, use of epidural catheters or adverse events bet ween groups. While intercostal liposomal bupivacaine injection is a safe method for rib fracture-related analgesia, it was not effective in reducing pain scores, opioid requirements, or hospital length of stay. Bupivacaine injection transiently improved incentive spirometry volumes, but without a reduction in the development of pneumonia. Therapeutic/care management, Level II.

Comparison of postoperative pain and pain control techniques in uniportal and biportal VATS and open surgery patients

Objectives: Thoracotomy causes intense postoperative pain which may become chronic. Video-assisted thoracic surgery (VATS)leads to less postoperative pain compared with thoracotomy. In this study, we analyzed pain scores in patients who underwent lungresections with VATS or thoracotomy.Patients and Methods: Patients who underwent lung resections with uniportal, biportal VATS or thoracotomy between May 2015– May 2017 were included in the study. Visual Analogue Scale (VAS) pain scores were recorded on postoperative day 1, 5 (or atdischarge), 2nd week, 1st and 3rd months. Patients were classified in 3 groups, uniportal VATS (n=178), biportal VATS (n=15),thoracotomy (n=60). Demographics, resection type, mortality, morbidity and epidural catheter use were recorded.Results: Two hundred and fifty-three patients (average age was 57.3 ± 12.7, 94 females) were included in the study. Median hospitalstay was 5 days. Uniportal and biportal groups had significantly lower pain scores in all intervals compared with thoracotomy. Nochronic pain was seen in VATS groups. Uniportal and biportal groups had similar pain scores at all times. Epidural use or size ofspecimen did not affect pain in VATS patients (p=0.18 vs p=0.68).Conclusion: Video-assisted thoracic surgery decreases the need for epidural patient control analgesia. Specimen size does not affectpostoperative pain and chronic pain is rare.

Chronic pain in lower limb amputees: Is there a correlation with the use of perioperative epidural or perineural analgesia?

Chronic pain is common in patients who undergo lower limb amputation. The use of epidural or perineural catheters seems to reduce acute pain after surgery but their effects in a longer follow up are unknown. To evaluate the long-term prevalence of phantom limb sensation (PLS), phantom limb pain (PLP), and residual limb pain (RLP) and their correlation with perioperative use of epidural or perineural catheters. Postal survey. Patients with trans-femoral, trans-tibial or hemi-pelvectomy amputation were asked to partake in the study. The Prosthetic Evaluation Questionnaire was used for the presence of chronic post-surgical pain. Use of catheters was retrieved from medical notes. 57 patients at a mean of 4.4 years follow up were included. PLS was reported in 68.4%, PLP in 63.2 % and RLP in 54.4% of amputees. No correlation was identified between pain syndromes and the presence of individual catheters and the duration of their permanence. The simultaneous use of 2 catheters was related to a lesser presence of PLP. Data on prevalence of PLP, PLS and RLP are consistent with the literature. Favourable effects in PLP reduction in the long term follow up was related to the simultaneous use of two catheters.

Implementation barriers for Enhanced Recovery After Surgery (ERAS) in rectal cancer surgery: a comparative analysis of compliance with colon cancer surgeries.

We aim to analyze differences in compliance between colon and rectal cancer surgeries under Enhanced Recovery After Surgery (ERAS) for colorectal procedures, and to detect implementation barriers for rectal cancer surgeries. Patients who underwent elective rectal cancer surgeries under ERAS were case-matched based on gender, age, and P-POSSUM with an equal number of patients who underwent colonic surgeries. Achievements of ≥ 70% of ERAS items were considered an acceptable level of compliance. A multivariate analysis was carried out to identify independent risk factors for lower compliance. A total of 434 patients were included over a 5-year period. After matching, there were 111 patients in each group. Overall compliance was significantly lower in the rectal surgery group (73% vs 82%, p = 0.001). A good compliance rate differed from 55% in rectal vs 77.5% in colonic procedures (p = 0.000). We identified three independent risk factors for lower compliance rates: open surgical approach, the use of epidural catheter, and the presence of postoperative ileus. Our data showed that rectal cancer surgeries are more exigent to success on ERAS interventions when compared to colonic resections. There is a need to introduce specific modifications on the protocols for colorectal surgeries when applied to these particular procedures.

Difficulty in Advancing Flexible Epidural Catheters When Establishing Labor Analgesia: An Observational Open-Label Randomized Trial.

While flexible epidural catheters reduce the risk of paresthesia and intravascular cannulation, they may be more challenging to advance beyond the tip of a Tuohy needle. This may increase placement time, number of attempts, and possibly complications when establishing labor analgesia. This study investigated the ability to advance flexible epidural catheters through different epidural needles from 2 commonly used, commercially available, epidural kits. We hypothesized that the multiorifice wire-reinforced polyamide nylon blend epidural catheters will have a higher rate of successful first attempt insertion than the single-end hole wire-reinforced polyurethane catheters for the establishment of labor analgesia. The primary outcome was a difference in proportions of failure to advance the epidural catheter between the 2 epidural kits and was tested by a χ2 test. Two-hundred forty epidural kits were collected (n = 120/group) for 240 laboring patients requesting epidural analgesia in this open-label clinical trial from November 2018 to September 2019. Two-week time intervals were randomized for the exclusive use of 1 of the 2 kits in this study, where all patients received labor analgesia through either the flexible epidural catheter "A" or the flexible epidural catheter "B." Engineering properties of the equipment used were then determined. Flexible epidural catheter "A," the single-end hole wire-reinforced polyurethane catheter, did not advance at the first attempt in 15% (n = 18 of 120) of the parturients compared to 0.8% (n = 1 of 120) of the catheter "B," the multiorifice wire-reinforced polyamide nylon blend epidural catheter (P < .0001). Twenty-five additional epidural needle manipulations were recorded in the laboring patients who received catheter "A," while 1 epidural needle manipulation was recorded in the parturients who received catheter "B" (P < .0001). Bending stiffness of the epidural catheters used from kit "B" was twice the bending stiffness of the catheters used from kit "A" (bending stiffness catheters "A" 0.64 ± 0.04 N·mm2 versus bending stiffness catheters "B" 1.28 ± 0.20 N·mm2, P = .0038), and the angle formed by the needle and the epidural catheter from kit "A" was less acute than the angle formed from kit "B" (kit "A" 14.17 ± 1.72° versus kit "B" 21.83 ± 1.33°, P = .0036), with a mean difference of 7.66° between the 2 kits' angles. The incidence of an inability to advance single-end hole wire-reinforced polyurethane catheter was higher compared to the use of multiorifice wire-reinforced polyamide nylon blend epidural catheter. Variation of morphological features of epidural needles and catheters may play a critical role in determining the successful establishment of labor epidural analgesia.

Knotted epidural catheter: the role of determining a catheter’s ultimate tensile strength before pulling on it. A case report and literature review

Knotting is a well-known but rare complication of the use of epidural catheters. We report the case of a knotted catheter successfully removed by simple traction, after determining its ultimate tensile strength. We reviewed the case reports published since 1979. We assessed the prevalence of this complication, the impact of placement technique on a knot’s occurrence, the value of the different imaging modalities, and the one of various techniques used for catheter removal. A knotted catheter can often be removed intact with steady and gentle traction. Before pulling on an entrapped catheter and to avoid breakage, it may be useful to assess its ultimate tensile strength on its free extremity or another identical catheter. Limiting the length of a catheter threaded in the epidural space during its insertion seems to be the best way to avoid knots.

Accidental dural puncture-perioperative management.

Accidental dural puncture-perioperative management.

Epidurale anesthesie en analgesie bij paarden

Epidurale anesthesie is een loco-regionale anesthesietechniek waarbij medicatie geïnjecteerd wordt in de epidurale ruimte. Deze techniek werd in de humane geneeskunde ontwikkeld in de 19e eeuw en later ook toegepast in de diergeneeskunde. Enerzijds is epidurale anesthesie nuttig voor staande ingrepen, maar het kan ook gebruikt worden als onderdeel van een gebalanceerde anesthesietechniek of voor postoperatieve pijnbestrijding. Anesthesie en analgesie kunnen bereikt worden voor het bekken, de achterbenen, staart, vagina, vulva, anus of perineum en het abdomen. Hoewel de techniek bij verschillende indicaties gebruikt kan worden, zijn er echter ook enkele tegenindicaties en kunnen er complicaties optreden. Bij paarden kan een epidurale anesthesie craniaal (lumbosacraal) of caudaal (sacro-coccygeaal of Co1-Co2) uitgevoerd worden. Naast enkelvoudige injecties kan ook een epidurale katheter geplaatst worden voor herhaaldelijke toediening. Afhankelijk van het gewenst effect kan er een keuze gemaakt worden uit verschillende types medicatie (lokale anesthetica, alfa-2 agonisten, opioïden, ketamine, tramadol, tiletamine-zolazepam), combinaties van medicaties en injectievolumes.