Epidural Catheter Insertion Research Articles

Accuracy of the epidural catheter position during the lumbar approach in infants and children: a comparison among L2-3, L3-4, and L4-5 approaches

BackgroundThe aim of this study was to compare the accuracy of the position of the epidural catheter inserted from three different lumbar intervertebral spaces, L2-3, L3-4, and L4-5, in infants and children.MethodsSeventy-five children were randomly allocated to 3 groups according to the epidural catheter insertion site (L2-3, L3-4, and L4-5). The epidural catheter tip was identified using 50% diluted Iohexol and fluoroscopy. The incidence of correct position was compared among the groups and between infants and children.ResultsThe incidence of correct position was significantly higher in the L2-3 group as compared to the L3-4 and L4-5 groups (P = 0.023 and P = 0.046 respectively). The incidence of correct position was higher in infants compared to children (P = 0.017).ConclusionsThe L2-3 intervertebral space is preferable during epidural catheter insertion in children older than 1 year, but a low lumbar level should be considered in infants because they have a higher risk of neural damage.

Underestimated role of alcohol at skin disinfection: lipid dissolving property when used in association with conventional antiseptic agents

After conventional aqueous disinfectant solutions, it was shown that microorganisms were still protected in hair follicles. We hypothesized that those aqueous disinfectant solutions when used in combination with alcohol may be more effective on the inhibition of recolonization of skin and therefore catheter tip colonization. Materials and methods: Skin surface samples were taken from epidural catheter insertion sites prior to catheterization, and before and after disinfection with different combinations of povidone-iodine, chlorhexidine, and alcohol. Before catheter removal, cultures were taken once more and tips of the catheters were cultured. Results: Catheter tip colonization and skin culture results of 10% povidone-iodine + 70% alcohol group were significantly lower than those of other groups after disinfection. Conclusion: Sequential use of alcohol and povidone-iodine is the most effective combination for limiting re-colonization of skin flora. Contamination of catheters appears to take place at removal or via the spread of these re-colonized bacteria along the catheter tract.

Normal Magnetic Resonance Appearance After Epidural Catheter Insertion

Normal Magnetic Resonance Appearance After Epidural Catheter Insertion

A Survey of Local Opinion of NICE Guidance on the Use of Ultrasound in the Insertion of Epidural Catheters

Obstetric Anesthesia Digest: June 2009 - Volume 29 - Issue 2 - p 109 doi: 10.1097/01.aoa.0000350654.43195.47

AUA Best Practice Statement for the Prevention of Deep Vein Thrombosis in Patients Undergoing Urologic Surgery

Summary of VTE prophylaxis recommendations Level of risk Prophylactic treatmentLow Risk ● No prophylaxis other than early ambulationModerate Risk ● Heparin 5000 units every 12 hours subcutaneous starting after surgery ● OR *Enoxaparin 40 mg. (Cr Cl 30 ml/min. 30 mg.) subcutaneous daily ● OR Pneumatic compression device if risk of bleeding is highHigh Risk ● Heparin 5000 units every 8 hours subcutaneous starting after surgery ● OR *Enoxaparin 40 mg. (Cr Cl 30 ml/min. 30 mg.) subcutaneous daily ● OR Pneumatic compression device if risk of bleeding is highVery High Risk ● *Enoxaparin 40 mg. (Cr Cl 30 ml/min. 30 mg.) subcutaneous daily and adjuvant pneumatic compression device, or ● Heparin 5000 units every 8 hours subcutaneous starting after surgery and adjuvant pneumatic compression device* Guidelines and Cautions for Enoxaparin Use ● In patients with a body weight 150 Kg. consider increasing prophylaxis dose of Enoxaparin to 40 mg. subcutaneous every 12 hours. ● Withhold Enoxaparin generally for at least 2 to 3 days after major trauma, and then only consider use after review of current patient condition and risk benefit ratio.

Spinal epidural hematoma after insertion of a thoracic epidural catheter in the absence of coagulation disorders - A call for raised awareness

Spinal epidural hematoma after insertion of a thoracic epidural catheter in the absence of coagulation disorders - A call for raised awareness

Neurological deficit after thoracic epidural catheter insertion

Neurological deficit after thoracic epidural catheter insertion

A survey of local opinion of NICE guidance on the use of ultrasound in the insertion of epidural catheters

In January, the National Institute for Health and Clinical Excellence (NICE) issued guidance on the use of ultrasound to facilitate catheterisation of the epidural space. In the published information, available to the public, the use of ultrasound compared with the ‘traditional landmark approach’ is quoted as being associated with fewer attempts, a decreased incidence of dural puncture and post procedure headache, and overall greater patient satisfaction [1]. These conclusions, which were based on obstetric and paediatric populations, and also on those requiring corrective back surgery, do not provide a balanced approach to the actual findings of the studies quoted. In two small studies involving neonates and children, there were no sound clinical end points that reached statistical significance [2, 3]. Further, we have reservations regarding the conclusions reached from the obstetric studies. In the three studies [4–6] where ultrasound was compared to a standard landmark technique (all cited from the same main author) there is no compelling statistical end point that favours the use of ultrasound. The decreased incidence of dural puncture quoted by NICE is based on two cases in the 150 control group (landmark) compared with one in the prepuncture ultrasound group. There are no statistical data for this [4]. In addition, whilst there were more cases of severe post-procedure headache in the control group (10% versus 2.7%) this actually grossly exceeds the number of dural punctures. Further, whilst ‘patient satisfaction with epidural space procedure’ was deemed to be higher in the ultrasound group, overall ‘patient satisfaction with general treatment’ was better in the control group. In pregnant women with a body mass index over 33 kg.m2, scoliosis, kyphosis, hyperlordosis or where there was anticipated difficulty in epidural insertion, fewer puncture attempts were required when ultrasound was used [5]. However, there were no recognised dural punctures in either group, and no statistical difference in failure rates or headaches. In a randomised control trial of 30 pregnant women comparing ultrasound and the landmark technique for the insertion of a combined spinal-epidural for Caesarean section, there was a significant reduction in the number of attempts using imaging. However, the success rate without ultrasound was unusually low, with 60% requiring more than one attempt [6]. We conducted a local email survey of anaesthetists in Wessex in light of these NICE guidelines. Of the 151 respondents, a 40% response rate, the majority being consultants, 97% have never used ultrasound to image the epidural space, although in the same geographical district it is common to use ultrasound both for regional anaesthesia and vascular access. Over 60% of respondents had received formal ultrasound teaching for the techniques that they used. In contrast, more than 90% were not aware of any courses that taught ultrasound techniques to identify the epidural space. Overwhelmingly, they concluded that without formal teaching, they would not find ultrasound guided epidural catheter insertion a useful technique. Ultrasound is an invaluable tool for anaesthetists both in vascular access and regional anaesthesia, its benefit in facilitating epidural catheter insertion is not demonstrated in the current literature referenced by the NICE guidelines. We agree that it has the potential to be a useful adjunct as a prepuncture method in those patients with difficult anatomical landmarks (obesity and back anomalies [7]). This will primarily be to obtain the level and estimated depth of the epidural space (accepting that some of the accuracy will be lost because of the probe compression, local anaesthetic infiltration and discrepancies in needle angle). In conclusion, there will need to be more evidence before most anaesthetists will be convinced of the usefulness of ultrasound for the placement of an epidural. The required infrastructure will need to be available before the NICE guidance can be adopted.

370: Epidural Abscess: Complication After Insertion of Epidural Catheter? A Case Report

370: Epidural Abscess: Complication After Insertion of Epidural Catheter? A Case Report

370. Epidural Abscess: Complication After Insertion of Epidural Catheter? A Case Report

370. Epidural Abscess: Complication After Insertion of Epidural Catheter? A Case Report

Epidural Abscess: Complication After Insertion of Epidural Catheter? A Case Report

Epidural Abscess: Complication After Insertion of Epidural Catheter? A Case Report

Ten years of experience with accidental dural puncture and post-dural puncture headache in a tertiary obstetric anaesthesia department

Accidental dural puncture (ADP) and post-dural puncture headache (PDPH) are important complications of obstetric regional anaesthesia. Between January 1997 and October 2006 in our tertiary obstetric referral centre 17 198 neuraxial blocks were recorded; 965 epidural, 16193 combined spinal-epidural and 40 spinal. Records of all parturients who experienced either ADP or PDPH were reviewed. There were 89 ADPs (0.5%), 55 observed and 34 in which PDPH followed unrecognised dural puncture. Following known ADP, 28 women had epidural catheters re-sited at a different lumbar interspace and 27 had intrathecal catheters for at least 24 h. Thirty-one women developed PDPH after observed ADP; the incidence of PDPH was similar after puncture with needle and catheter, after epidural and CSE techniques, after 27- and 29-gauge pencil-point spinal needles and after spinal and epidural catheter insertion (61% vs 52%; P>0.05). All headaches presented within 72 h. A blood patch was needed in 26/55 women after known ADP and 27/34 unrecognised ADP. A repeat blood patch was needed in 8 (15%). The incidence of ADP, PDPH, blood patching and repeat blood patching is similar to previous studies. Many ADPs are unrecognised during epidural insertion. CSE does not appear to increase the risk of ADP or PDPH; 29-gauge rather than 27-gauge pencil-point spinal needles conferred no benefit. Inserting the epidural catheter intrathecally did not significantly reduce the incidence of PDPH and blood patching in our series.

Predistention of the Epidural Space Before Catheter Insertion Reduces the Incidence of Intravascular Epidural Catheter Insertion

Evron, S.* †; Gladkov, V.*; Sessler, D.I.† ‡; Khazin, V.*; Sadan, O.§; Boaz, M.∥; Ezri, T.* † Author Information

Intrapleural Misplacement of a Thoracic Epidural Catheter in an Anesthetized Patient

Thoracic epidural analgesia provides adequate postoperative pain relief and favorable outcomes in major operations. However, a small number of devastating complications have been reported. Here we present a case of asymptomatic but potentially life-threatening intrapleural insertion of a thoracic epidural catheter intended for postoperative analgesia. A 39-year-old male diagnosed with esophageal carcinoma was scheduled for esophageal reconstruction. After induction of general anesthesia, a thoracic epidural catheter was inserted with a paramedian approach at the T8-9 interspace, using loss of resistance to ensure correct placement. The administration of a test dose of 2% lidocaine with epinephrine was unremarkable. After right thoracotomy, the epidural catheter was found in the right pleural cavity and was instantly removed. The patient underwent the operation smoothly and was discharged 10 days later without any sequelae. We recommend practitioners estimate the depth from the skin to the epidural space by computed tomography scan before operation and perform the placement of thoracic epidural catheter while the patient is awake to avoid accidental intrapleural misplacement.

Technical aspects of high thoracic epidural analgesia in cardiac surgery

This review focuses on technical aspects of high thoracic epidural analgesia (TEA) when used in conjunction with general anesthesia for patients undergoing cardiac surgery. Several issues are discussed: the type of surgery, the importance of anticoagulation, and the timing of the TEA insertion. In addition, practical concerns, such as the type and dose of local anesthetics and possible adjuncts, the duration of TEA treatment, the interaction between TEA and postoperative anticoagulation, or the consequence of inadvertent bloody tap, are presented. This author proposes the insertion of the thoracic epidural catheter at least 1 hour before heparinization, in the high thoracic region via median approach. Correct positioning of the catheter, which should be fixed with a secure dressing device, can be achieved via the injection of 2 mL lidocaine 1% with epinephrine 1:200,000. Should a bloody tap occur, a distinction between venous and arterial origin should be made and surgery postponed for at least 24 hours, only in the case of arterial tap. Trouble-shooting for commonly encountered problems with TEA in cardiac surgery is outlined as well as management of suspected epidural hematoma.

Local Infiltration of Epinephrine-Containing Lidocaine With Bicarbonate Reduces Superficial Bleeding and Pain During Labor Epidural Catheter Insertion

Local Infiltration of Epinephrine-Containing Lidocaine With Bicarbonate Reduces Superficial Bleeding and Pain During Labor Epidural Catheter Insertion

Predistention of the Epidural Space Before Catheter Insertion Reduces the Incidence of Intravascular Epidural Catheter Insertion

Accidental cannulation of an epidural vein is a common complication associated with epidural anesthesia or analgesia. On the basis of a pilot study and previous reports, we tested the hypothesis that predistention of the epidural space with saline before epidural catheterization would ease catheter insertion and decrease the incidence of this complication. Two-hundred-three laboring women were randomly assigned to receive an epidural with loss of resistance technique with 2 mL (nondistention) or 5 mL saline (distention). In the distention group, the syringe plunger was held closed before epidural catheter insertion. Then in both groups, a test dose of 3 mL of 1.5% lidocaine was injected through the epidural catheter. There were fewer accidental intravascular catheter placements (2% vs 16%, P = 0.0001) in the distention group, and 91% of patients in this group did not have any unblocked segments versus 67% in the nondistension group (P = 0.0001). The difference in onset time of analgesia was small (5.0 +/- 2 min vs 6 +/- 3 min, P = 0.0001) and not clinically important. The quality of analgesia (visual analog scores and ropivacaine consumption) was similar between groups. Distention of the epidural space with 5 mL saline before epidural catheter insertion decreased the incidence of accidental venous cannulation and the number of unblocked segments.

Perioperative Epidural Anaesthesia and Analgesia—An Appraisal of Its Role

Perioperative epidural anaesthesia and analgesia (PEA) has become controversial because of its doubtful effect on patient outcome and its serious complications. These scientific considerations have been affected by the changing medicolegal climate in Australia and has led to a reappraisal of this technique in our practice of anaesthesia. Many anaesthetists are now uncertain about indications, consent requirements, optimal management and the prevention and early detection of complications of PEA. The aim of this paper is to present a personal perspective of the place and use of PEA in current anaesthetic practise. The primary indication for PEA should be pain relief for open abdominal or thoracic surgery because there is level 1 evidence that it provides better analgesia than parenteral opioids. There is reasonable evidence that outcome is improved but the studies are conflicting. Coagulation status needs to be assessed carefully before the insertion and removal of epidural catheters. Consent issues are difficult in practice, both from the timing and the content of the information. The decrease in the use of PEA may paradoxically result in more complications as loss of expertise becomes an issue. PEA is labour intensive and therefore needs the support of an Acute Pain Service in order to use this technique safely and recognise problems early. Permanent neurological complications are the most feared complication of this technique but early recognition of these problems can improve outcome. These complications need to be balanced against the potentially serious hypoxaemia associated with parenteral opioids used for postoperative pain relief

34th Annual Scientific Meeting of the Association of Paediatric Anaesthetists of Great Britain and Ireland, 8?10 March 2007, Manchester. Spread of local anaesthetic solution in epidural space visualisation with ultrasound in single shot caudals

Background: Ultrasonography is becoming an important adjunct in paediatric neuraxial blockade. Ultrasound guidance helps in visualisation of relevant neuraxial structures, predicting depth of epidural space from skin, reduction in bony contact and faster epidural placement. The visibility of neuraxial structures declines in patients as age increases. To date, there are no studies looking at the extent of spread of local anaesthetic solution in the epidural space and its correlation to the volume used, under ultrasound guidance. We report the results of our audit on spread of local anaesthetic solution in the epidural space in single shot caudal blocks. This abstract is based on the first 17 patients, the presentation will be based on all 50 patients. Methods: This audit was approved by the local audit committee. We aimed to follow the extent of the spread of local anaesthetic within the epidural space with real time ultrasonography. Patients were selected when the planned anaesthetic included a single shot caudal block. The anaesthetists performing the anaesthetic and the caudal block consented to our ultrasound visualisation. All patients were below 5 years of age. No attempt was made to standardise the technique, the dose, or the speed of injection. After the placement of the caudal cannula by the primary anaesthetist involved in patient care, a separate anaesthetist, experienced in using ultrasound, visualised the neuraxial structures and subsequent spread of the local anaesthetic solution with real time ultrasound. The spread was followed during the injection and for 10 s after the completion of the injection. A 5 cm 7.5–12 MHz linear array was used longitudinally with either midline or paramedian approach. Results: We are reporting the preliminary results from 17 patients. Patients were aged between 1 day and 1 year 10 months. They weighed between 3.3 kg and 14.6 kg. Either 22 gauge Jelco or Abbocath were used to perform the procedure; 0.25% or 0.20% L-bupivacaine was used on all occasions. The volume administered per kg ranged between 0.33 and 1.27 ml. The visibility of neuraxial structures was good on all occasions. On calculating the Spearmans correlation coefficient, the extent of spread of local anaesthetic in the epidural space was positively correlated with the volume used by a correlation coefficient of 0.64, with a P value of 0.008. The postoperative pain score in recovery was 0 in 16 out of the 17 cases. The one failure occurred when the observed spread would not have been expected to provide analgesia for the performed operation. Conclusions: Among children below 5 years of age, there seems to be a positive correlation between the volume of local anaesthetic injected into the epidural space and the extent of its spread. This needs to be further investigated by a prospective randomised control trial. The utility of real time ultrasound to allow a reliable achievement of a desired level of sensory block, should be investigated i.e, whether the volume used in achieving a desired level of local anaesthetic spread, as guided by ultrasound, provides superior analgesia and fewer adverse effects compared with the volume calculated using the Armitage regimen. References 1 Rapp HJ, Folger A, Grau T. Ultrasound guided epidural catheter insertion in children. Anesth Analg 2005; 101: 333–339. 2 Willschke H, Marhofer P, Bosenberg A, et al. Epidural catheter placement in children: comparing a novel approach using ultrasound guidance and a standard loss of resistance technique. Br J Anaesth 2006; 97: 200–207. 3 Marhofer P, Bosenberg A, Sitzwohl C et al. Pilot study of neuraxial imaging by ultrasound in infants and children. Pediatr Anesth 2005; 15: 671–676.

Local infiltration of epinephrine-containing lidocaine with bicarbonate reduces superficial bleeding and pain during labor epidural catheter insertion: a randomized trial

Superficial bleeding after labor epidural catheter placement is a common phenomenon. In addition to delaying securing the epidural catheter, it may loosen the adhesive catheter dressing. The primary aim of this study was to determine whether skin infiltration with epinephrine-containing rather than plain lidocaine reduces superficial bleeding after catheter placement. Secondary objectives were to determine whether adding epinephrine and/or sodium bicarbonate affected infiltration pain. After institutional review board approval and informed consent, 80 healthy women receiving epidural analgesia during labor were randomly assigned in a double-blind manner to four local anesthetic mixtures (n=20 in each group): group L: lidocaine 1.5%, group LB: lidocaine 1.5% with 8.4% sodium bicarbonate, group LE: lidocaine 1.5% with epinephrine 1:200000, and group LEB: lidocaine 1.5% with epinephrine 1:200000 and 8.4% sodium bicarbonate. Clinical endpoints included the amount of superficial bleeding at the catheter site, pain during local anesthetic infiltration and epidural catheter movement during labor. Demographic data were similar among the groups. The addition of epinephrine to lidocaine significantly reduced superficial bleeding. Solutions containing epinephrine were well tolerated and caused no cardiovascular disturbances. The addition of epinephrine did not increase pain, while bicarbonate reduced it [verbal score (scale 0-10) 3.6+/-2.2 vs. 2.6+/-1.8; P=0.04]. There were no differences in epidural catheter movement among the groups; no catheters became displaced during labor. Local infiltration of epinephrine-containing lidocaine before epidural catheter insertion reduces superficial bleeding and the addition of bicarbonate decreases pain during skin infiltration.