Epidural catheter fixation: subcutaneous tunnelling with a loop to prevent displacement

A method of fixing the epidural catheter by subcutaneous tunnelling and looping was devised. A prospective, randomised, double-blind, clinical trial was conducted in 68 adult patients, where postoperative pain relief was planned by thoracic epidural analgesia. In the tunnelled group (n = 34), the epidural catheter was fixed with a subcutaneous tunnel and loop, whereas in controls (n = 34), a simple loop of epidural catheter was left over the skin without tunnelling. An adhesive dressing was used to secure the epidural catheter. We observed that catheter dislodgement occurred in only one patient in the tunnelled group compared to seven control patients (21%). Despite local inflammation of the skin around the tunnel in nine patients (27%), no catheter infection (positive culture tip) was found in patients with subcutaneous tunnelling for the extended period of 4-5 days. The method described allows the catheter to lie flat on the skin and outward traction of the catheter during movement of patients is dampened by the interposed loop which protects it against dislodgement. At the time of removal, both ends of the catheter can be removed under direct vision. In conclusion, we recommend this fixation method in cases where epidural analgesia is to be used for postoperative pain relief.     

Epidural catheter migration during labour — A comparison between standard versus Epi-Guard fixation

Canadian Journal of Anesthesia/Journal canadien d'anesthésie -     

Epidural catheter migration: a comparison of tunnelling against a new technique of catheter fixation

We investigated the efficacy of a new technique of epidural catheter fixation that relies on a strip of adhesive foam transfixed by a securing suture. We compared this technique to a tunnelled technique in a prospective, randomized trial (n = 25 in each group). Epidural catheter depth was recorded at the time of insertion and at the time of removal. Clinically significant catheter movement was considered as > 2 cm outward movement or > 1 cm inward movement. The mean duration of epidural analgesia was five days for both groups. Clinically significant movement was noted in eight patients (32%) in the tunnelled group and seven patients (28%) in the sutured group (P = 0.75). Movement of the epidural catheter did not correlate with analgesic failure. The sutured technique provided similar protection against migration to tunnelling but any potential advantages were offset by concerns about a significantly higher incidence of erythema around the catheter exist site in the sutured group (1 vs 6 patients, P = 0.04).     

Epidural anesthesia

In epidural anaesthesia, the anaesthetist injects one or more drugs into the epidural space bordering on the spinal dura mater to achieve a "central" and/or "neuraxial" block. It is one of the earliest techniques in anaesthesia, originally performed exclusively with local anaesthetic agents. Adding other drugs and combining epidural with general anaesthesia or adapting the technique to the needs of children has extended the list of indications. Continuous epidural analgesia is an important tool in postoperative pain management. More and more often, the increasing proportion of patients who have comorbidities or are permanently taking medication that modulates the clotting system demands that the anaesthesiologist balance the individual risks and benefits before inducing epidural anaesthesia.     

Epidural abscesses

Until recently epidural abscess was considered a rare, almosttheoretical, complication of central nerve block, but anecdotalreports suggest that this is no longer the case. Thus a reviewof the risk factors, pathogenesis, clinical features and outcomeof this condition is appropriate, the primary aim being to makerecommendations on best anaesthetic practice to minimize therisk of this serious complication. A search of EMBASE©,PUBMED© and MEDLINE© databases from 1966 to September2004 was performed using several strategies, supplemented byreference list screening. Spontaneous epidural abscess is rare,accounting for 0.2–1.2 cases per 10 000 hospital admissionsper year. Estimates of the incidence after central nerve blockvary from 1:1000 to 1:100 000. Risk factors (compromised immunity,spinal column disruption, source of infection) are present inthe majority of patients, whether the condition is spontaneousor associated with central nerve block. Presentation is vague,fever and back pain usually preceding neurological deficit.Diagnosis requires a high index of suspicion and modern imagingtechniques. Treatment involves early surgical drainage to preventpermanent deficit and high dose parenteral antibiotics chosenwith bacteriological advice. Primary prevention depends on properuse of full aseptic precautions. Epidural abscess can be a catastrophicconsequence of central nerve block. Early diagnosis will minimizepermanent damage, but primary prevention should be the aim.There is a need for a large survey to indicate the true incidenceto better inform the risk–benefit ratio for central nerveblock.     

Epidural lipomatosis

ONSET: Epidural lipomatosis is a rare disorder defined as a pathological overgrowth of normal epidural fat. It is more often associated with administration of exogenous steroid with variable duration and doses. Furthermore, it may occur in some patients in the absence of exposure to steroids but generally associated with obesity. Whatever the predisposing factor, the majority of these patients are men. The causal effect of epidural lipomatosis in the development of spinal cord or radicular compression is generally well accepted. DIAGNOSIS: The diagnosis of epidural lipomatosis can be established by melography, computed tomography (CT) and magnetic resonance imaging (MRI). MRI is considered the imaging procedure of choice, allowing an assessment of the extent of lipomatosis and, as well as CT, an identification of the lipomatous tissue. Most cases of epidural lipomatosis with corticosteroid use occur in the thoracic region, while most idiopathic cases occur in the lumbar region. TREATMENT: Management of treatment depends on the severity of the neurological signs and the patient's background. The most common treatment for epidural lipomatosis with corticosteroid use consists in surgical decompression but with a high risk of postoperative mortality. In some cases however, medical treatment includes corticosteroid withdrawal or reduction and calorie restriction, leading to clinical improvement. Treatment for idiopathic epidural lipomatosis is more often medical, based on weight loss and physical therapy with generally successful outcome. The pathogenesis of epidural lipomatosis remains unknown but different suggested hypotheses may lead to a metabolic disorder as the underlying cause.