|LETTER TO EDITOR
|Year : 2018 | Volume
| Issue : 12 | Page : 1009-1010
Epidural catheter displacement – A report of delayed diagnosis
Rishabh Jaju, Bharat Paliwal, Priyanka Sethi, Pradeep Bhatia
Department of Anaesthesiology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
|Date of Web Publication||10-Dec-2018|
Dr. Rishabh Jaju
Department of Anaesthesiology, All India Institute of Medical Sciences, Jodhpur - 342 005, Rajasthan
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Jaju R, Paliwal B, Sethi P, Bhatia P. Epidural catheter displacement – A report of delayed diagnosis. Indian J Anaesth 2018;62:1009-10
Epidural catheter migration or displacement is a known entity with an incidence up to 50%. We report a case in which catheter displacement was missed with its consequent effect. A 22-year-old male posted for plating of fracture shaft of femur and tibia was given combined spinal–epidural anaesthesia at L3–L4 interspace in sitting position. Epidural catheter was threaded about 5 cm in the epidural space without difficulty and fixed at 9 cm mark at skin by a transparent dressing. About 1 h after spinal anaesthesia, epidural infusion of 0.5% bupivacaine was started at 5 ml/h. Surgery lasted for 4 h uneventfully. Postoperatively ropivacaine 0.2% with 2 μg/ml fentanyl was continued at 6–7 ml/h through epidural catheter. Diclofenac 75 mg IV was prescribed as rescue analgesic for the Visual Analogue Scale (VAS) score >4. Epidural infusion was continued for 48 h. At follow-up, round VAS score was 3–4 at 6, 12, 18, 24, 36 and 48 h so the infusion was continued till 48 h postoperatively with no signs of inflammation. But catheter looping masked proper visualisation of its markings. At the time of epidural catheter removal we found swelling over the back from the lower thoracic to lumbar region and catheter marking at skin was just 3 cm [Figure 1]a. There were no local signs of inflammation like redness, fever or pain. Screening ultrasound revealed fluid in the subcutaneous space. Computed tomography (CT) scan delineated collection extending posterolaterally from T10 to L5. The collection was likely to be drug administered through epidural infusion [Figure 1]b. Patient remained asymptomatic and swelling subsided in 48 h after catheter removal.
|Figure 1: (a) Swelling over back of the patient with no signs of inflammation. (b) Compute tomography image depicting presence of fluid in subcutaneous space ranging from T10 to L5|
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In this case catheter got displaced leading to drug accumulation in the subcutaneous space. Misjudgement of inserted depth of epidural catheter and masking of inadequate analgesia due to concomitant analgesics led to delayed diagnosis of catheter displacement. This case highlights few important points for epidural catheter management. Looping of epidural catheter during fixation to prevent dislodgement may cause erroneous judgment of actual insertion depth on follow up. The other factors which are likely to contribute in improper assessment are inaccessibility from patient's supine position, masking of the area from clothing and coexisting dependent oedema.
Often insertion site is inspected for soakage or local signs of inflammation but examination of actual fixation markings may be overlooked. Several circumstantial factors add to this casual approach. First, adequate pain relief is assumed to be a surrogate marker of appropriately placed catheter. Second, in absence of proper depth documentation no absolute value of catheter marking at skin level can ensure proper placement. As not only depth of epidural space from skin is variable, depth of catheter inside the epidural space is often individualised (4–6 cm). Finally, inadequate pain relief is attributed to patchy/ineffective/partially effective epidural and covered empirically with supplemental analgesics. In our case too review of ward records revealed that injection diclofenac was administered empirically thrice a day and this masked inadequate epidural analgesia. Proper documentation of depth of insertion along with vigilant monitoring of the site of epidural catheter insertion is a must. In cases of inadequate functioning of epidural catheter, malpostioning should be ruled out before contemplating additional parenteral analgesics.
Careful evaluation of epidural site at every visit can prevent such events. Meticulous care must be taken while patient positioning and shifting. In cases where extravasation of the drug dose occurs, patient must be followed for signs of infection till the fluid is absorbed.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Day Y, Graham D. Epidural catheter migration. Anaesthesia 2002,57:418.
Hermanides J, Hollmann MW, Stevens MF, Lirk P. Failed epidural: Causes and management. Br J Anaesth. 2012;109:144-54.