Administration of local anesthetic through the epidural needle before catheter insertion improves the quality of anesthesia and reduces catheter-related complications

Epidural catheter placement offers flexibility in block management. However, during epidural catheter insertion, complications such as paresthesia and venous and subarachnoid cannulation may occur, and suboptimal catheter placement can affect the quality of anesthesia. We performed this prospective, randomized, double-blind study to assess the effect of a single-injection dose of local anesthetic (20 mL of 2% lidocaine) through the epidural needle as a priming solution into the epidural space before catheter insertion. We randomized 240 patients into 2 equal groups and measured the quality of anesthesia and the incidence of complications. In the needle group (n = 100), catheters were inserted after injection of a full dose of local anesthetic through the needle. In the catheter group (n = 98), the catheters were inserted immediately after identification of the epidural space. Local anesthetic was then injected via the catheter. We noted the occurrence of paresthesia, inability to advance the catheter, or IV or subarachnoid catheter placement. Sensory and motor block were assessed 20 min after the injection of local anesthetic. Surgery was initiated when adequate sensory loss was confirmed. In the catheter group, the incidence of paresthesia during catheter placement was 31.6% compared with 11% in the needle group (P = 0.00038). IV catheterization occurred in 8.2% versus 2% of patients in the catheter and needle groups, respectively (P = 0.048). More patients in the needle group had excellent surgical conditions than the catheter group (89.6% versus 72.9; P < 0.003). We conclude that giving a single-injection dose via the epidural needle before catheter placement improves the quality of epidural anesthesia and reduces catheter-related complications.     

Small risk of serious neurologic complications related to lumbar epidural catheter placement in anesthetized patients

Previous studies have identified pain during needle/catheter placement or during the injection of local anesthetic as a risk factor for the development of persistent paresthesias after regional anesthetic techniques. The performance of regional blockade on anesthetized patients theoretically increases the risk of postoperative neurologic complications, because these patients are unable to respond to painful stimuli. In this study, we evaluated the frequency of neurologic complications in 4298 thoracic surgical patients undergoing lumbar epidural catheter placement while under general anesthesia. Catheters were placed immediately after the induction and tracheal intubation or on completion of the surgical procedure, before emergence. Most epidural catheters (4220, or 98.2%) were used solely for postoperative analgesia; only 78 (1.8%) epidural catheters were used for intraoperative anesthesia. In 4239 (98.6%) patients, an opioid alone was administered. The remaining 56 (1.3%) patients received a local anesthetic or local anesthetic/opioid mixture epidurally. Analgesia was graded as excellent or good in 92.2% of patients. Side effects included sedation in 455 (10.6%), nausea or emesis in 328 (7.6%), pruritus in 116 (2.7%), and respiratory depression (pH or=50 mm Hg) in 308 (7.2%) patients. The mean duration of epidural analgesia was 2.4 +/- 0.8 days (range, 0-10.7 days). There were no neurologic complications, including spinal hematoma, epidural abscess or catheter site infections, radicular symptoms, or persistent paresthesias (95% confidence interval, 0%-0.08%). In one patient, the epidural catheter broke during removal, and a portion was retained. The patient was notified; no long-term sequelae were noted. Six patients developed new neurologic symptoms or postoperative worsening of a previous neurologic condition unrelated to epidural catheterization. We conclude that the risk of neurologic complications associated with lumbar epidural catheter placement in anesthetized patients is small. However, the relative risk of this practice, compared with epidural catheter placement in awake patients, is unknown. IMPLICATIONS: We report no neurologic complications in 4298 patients undergoing epidural catheter placement while under general anesthesia. Although the risk of neurologic complications associated with lumbar epidural catheter placement in anesthetized patients is small, the relative risk compared with epidural catheterization in awake patients is unknown.     

Injecting saline through the epidural needle decreases theiv epidural catheter placement rate during combined spinal-epidural labour analgesia

PURPOSE: To determine if injecting 10 mL saline before epidural catheter threading (pre-cannulation epidural fluid injection) can decrease the incidence of iv epidural catheter placement during combined spinal-epidural (CSE) labour analgesia. METHODS: One hundred healthy women requesting CSE labour analgesia with either fentanyl 20 microg or sufentanil 10 microg were prospectively randomized to receive either no epidural injection (dry group, n = 50) or epidural 10 mL saline injection (saline group, n = 50) before epidural catheter placement. A nylon multiport catheter was then threaded 3-5 cm into the epidural space and the needle was removed. We diagnosed iv catheter placement if blood was freely aspirated, if the mother became tachycardic after injection of epinephrine 15 microg, or if intracardiac air was heard (using ultrasound) after injection of air 1.5 mL. RESULTS: Intravenous epidural catheter placement occurred in one saline and ten dry group patients (P < 0.01). No complications of excessive cephalad intrathecal opioid spread (i.e., difficulty swallowing, hypoxemia, or respiratory arrest) occurred. CONCLUSIONS: Injecting 10 mL or saline through the epidural needle after intrathecal opioid injection and before threading the catheter significantly decreased accidental venous catheter placement without any apparent increase in complications from excessive cephalad intrathecal opioid spread.     

An evaluation of commonly employed central venous catheter kits and their potential risk for complications of excess guidewire introduction

STUDY OBJECTIVE: To evaluate the components of commonly used central venous catheter kits with respect to the potential for guidewire-mediated complications during catheter placement.Prospective, nonrandomized, observational study. SETTING: Six academic hospitals across the United States. PATIENTS: None. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: 30 commercially manufactured catheter kits (15 tunneled, 15 nontunneled) were opened and evaluated. The catheter or sheath to be introduced was measured and a corresponding ideal guidewire length was calculated. The ideal length was then compared to the actual length, and differences were tabulated. Wire tip configuration and the presence and pattern of distance markings were recorded and, in conjunction with the catheter and wire length discrepancies, were used to grade the relative risk of introducing excess guidewire during catheter placement. Of 30 kits evaluated, 14 (46.7%) had guidewires more than 20 cm longer than necessary. The mean excess wire length was 15 cm (range: 8 to 55 cm) and did not differ significantly between tunneled and nontunneled catheter kits. Only 10 kits (33.3%) had distance markings of any type, and there was no standardization among them; none corresponded to previously published recommendations. There was potential risk of excess wire introduction in 18 catheter kits, of which seven were nontunneled devices designed for bedside placement. CONCLUSIONS: The design of commonly employed central venous access catheter kits is such that there is a mismatch between guidewire and catheter length and a general lack of guidewire markings. We believe that these designs may predispose to the introduction of excess guidewire and result in guidewire-mediated complications during catheter placement. This risk can likely be reduced by matching the guidewires to the devices placed over them and by standardizing guidewire distance markings.     

Epidural block: technical aspects and complications

In continuous epidural anaesthesia we rely heavily on the 'test dose' to confirm correct placement of the catheter. This is not always accurate and there are a number of new techniques designed to provide better information about epidural needle and catheter placement. These include: electrical stimulation of the catheter, use of ultrasound and the application of simple geometry. The use of epidurals in patients undergoing coronary artery bypass graft surgery is controversial because of the risk of vertebral canal haematoma. Neurological complications may arise during administration of the block, since the needle or catheter may result in direct nerve trauma. The injection of irritant drugs can also cause neurological damage. We must therefore be meticulous when injecting drugs into the epidural space. The increasing use of anticoagulant therapy in surgical patients and, in particular, the variety of low molecular weight heparins available, may make it difficult to safely perform epidural anaesthesia.     

Subarachnoid hemorrhage due to retained lumbar drain

Intrathecal spinal catheters (lumbar drains) are indicated for several medical and surgical conditions. In neurosurgical procedures, they are used to reduce intracranial and intrathecal pressures by diverting CSF. They have also been placed for therapeutic access to administer drugs, and more recently, vascular surgeons have used them to improve spinal cord perfusion during the treatment of thoracic aortic aneurysms. Insertion of these lumbar drains is not without attendant complications. One complication is the shearing of the distal end of the catheter with a resultant retained fragment. The authors report the case of a 65-year-old man who presented with a subarachnoid hemorrhage due to the migration of a retained lumbar drain that sheared off during its removal. To the best of the authors' knowledge, this is the first case of rostral migration of a retained intrathecal catheter causing subarachnoid hemorrhage. The authors review the literature on retained intrathecal spinal catheters, and their findings support either early removal of easily accessible catheters or close monitoring with serial imaging.     

Minimally invasive retrieval of knotted nonstimulating peripheral nerve catheters

OBJECTIVE: Continuous peripheral nerve blockade is rapidly becoming the technique of choice for the management of postoperative orthopedic pain. However, the insertion of perineural catheters may be associated with complications, including catheter kinking and knotting. A knotted catheter may be difficult or impossible to remove at the patient bedside, requiring surgical excision under general anesthesia. We describe a previously unreported minimally invasive technique of retrieving knotted peripheral nerve catheters and avoiding the need for surgical intervention. Although the described technique has been used by interventional radiologists for the removal of knotted intravascular devices, it has not been previously described for the retrieval of knotted perineural catheters. BRIEF REPORT: The Mayo Clinic Acute Pain Service database was queried and patients identified with knotted peripheral nerve catheters during the 3-year period from January 2003 to January 2006. The medical records of all identified patients were retrospectively reviewed and details of catheter placement including catheter type and location, size (gauge), ease of placement, distance threaded, and duration of use recorded. During the study period, 5,964 nonstimulating peripheral nerve catheters were placed. Of these, 8 (0.13%) patients experienced catheter knotting resulting in difficult or impossible catheter removal at the bedside. Seven (88%) of the 8 catheters were successfully removed by using a minimally invasive technique of catheter retrieval using guided fluoroscopy. The remaining catheter was removed at the bedside with patient repositioning. CONCLUSIONS: The knotting of peripheral nerve catheters is a relatively uncommon phenomenon, occurring in only 0.13% of patients. However, because the use of perineural catheters has increased within anesthesia practice, clinicians may begin to encounter these complications with greater frequency. Practitioners should be aware of surgical alternatives, including guided-fluoroscopic techniques, when simple catheter traction or tension proves unsuccessful at the patient bedside.     

Polyurethane Catheters for Long-Term Hemodialysis Access

Abstract: Chronic hemodialysis patients with failed native fistulas and/or synthetic arteriovenous grafts are usually dialyzed via surgically placed silicone jugular catheters such as the PermCath (Quinton, Seattle, WA, U.S.A.). We report a successful experience with the use of double lumen polyurethane central venous catheters placed percutaneously. Catheters with poor flows were replaced over a guidewire at the bedside. Eleven long-term hemodialysis patients failed arteriovenous access, 9 of them having had multiple attempts at fistulas and/or grafts. Seven of these patients had also failed peritoneal dialysis. They were dialyzed with polyurethane catheters for a mean of 681 ± 280 days (range 282–1150 days), requiring a mean of 3.4 ± 0.4 new venous punctures and 8.2 ± 1.5 catheter changes over a guidewire over that period of time. Actuarial patient survival was 50% at 2 years, and mean urea reduction during dialysis was 64.2 ± 1.7%. The septicemia rate was only 1.2 episodes per 1,000 catheter-days, but about 20% of patients experienced central venous occlusion, attributable to the use of subclavian catheter placement in 82% of the sites. The success of this technique and its elimination of the need for urokinase, radiologic interventions, and surgical placement warrant its consideration as an acceptable form of long-term vascular access, provided jugular placement allows reduced central venous occlusion rates.     

Central venous catheter placement: comparison of the intravascular guidewire and the fluid column electrocardiograms

BACKGROUND AND OBJECTIVE: Placement of central venous catheters in patients is associated with several risks including endocardial lesions and dysrhythmias. Correct positioning of central venous catheters in the superior vena cava is essential for immediate use. The objective of a first study was to evaluate the signal quality of an intravascular electrocardiogram (ECG) during position control using a guidewire compared with the customary fluid column-based ECG system, and to assess its efficacy of correct placement of the central venous catheter. A second study tested if dysrhythmias can be avoided by intravascular ECG monitoring during catheter and guidewire advancement. METHODS: The jugular or subclavian vein of 40 patients undergoing heart surgery or who were being treated in the intensive care unit was cannulated. Intravascular ECGs were recorded during position control, and guidewire and water column lead were compared in the same patient with regard to the quality of the ECG reading and P-wave enhancement. In another 40 patients, the guidewire was inserted only 10 cm and the central venous catheter advanced under guidewire ECG control. Correct position of all the central venous catheters was confirmed by chest radiography. RESULTS: All central venous catheters were correctly positioned in the superior vena cava. For the same catheter position, the P-wave was significantly larger in the guidewire ECG than in the fluid column system. No changes in the quality of the ECG were detected when the guidewire was advanced or withdrawn by 1 cm relative to the catheter tip. Cardiac dysrhythmias were not seen during ECG-monitored advancement of the guidewire. CONCLUSIONS: ECG quality using a guidewire lead is superior to the water column-based system. Furthermore, it is independent from the exact position of the guidewire as related to the tip of the catheter. Using intravascular guidewire ECG during advancement can prevent induction of dysrhythmias.     

A prospective randomised trial comparing insertion success rate and incidence of catheterisation‐related complications for subclavian venous catheterisation using a thin‐walled introducer needle or a catheter‐over‐needle technique

In clinical practice, both a thin‐walled introducer needle and catheter‐over‐needle technique can be used to allow insertion of a guidewire during central venous catheterisation using the Seldinger technique. We compared the incidence of catheterisation‐related complications (arterial puncture, haemothorax, pneumothorax, haematoma and catheter tip malposition) and insertion success rate for these two techniques in patients requiring right‐sided subclavian central venous catheterisation. A total of 414 patients requiring infraclavicular subclavian venous catheterisation were randomly allocated to either a thin‐walled introducer needle (needle group, n = 208) or catheter‐over‐needle technique (catheter group, n = 206). The catheterisation‐related complication rate was lower in the needle group compared with the catheter group (5.8% vs. 15.5%; p = 0.001). Overall insertion success rates were similar (97.1% and 92.7% in the needle and catheter groups respectively; p = 0.046), although the first‐pass success rate was higher in the needle group (62.0% vs. 35.4%; p < 0.001). We recommend the use of a thin‐walled introducer needle technique for right‐sided infraclavicular subclavian venous catheterisation.     

Detection of subarachnoid and intravascular epidural catheter placement

PURPOSE: To report the detection of subarachnoid and intravascular catheter placement using nerve stimulation through an epidural catheter. CLINICAL FEATURES: Electrical stimulation (1-10 mA) was applied through the catheter. A positive motor response (truncal or limb movement) indicated that the catheter was in the epidural space. Absence of a motor response indicated that it was not. A low milliamperage (<1 mA) with bilateral response indicated subarachnoid placement. Intravascular catheter placement was indicated by a positive response to the test, which remains at or returns to the baseline levels (i.e. prior to any local anesthetic injection), despite the administration of local anesthetics. In the first patient, the test confirmed subarachnoid catheter placement during attempts at continuous spinal anaesthesia even though CSF could not be aspirated. Bilateral motor response in the legs was observed at 0.2 mA. In the second patient, inadvertent subarachnoid placement was detected during attempted lumbar epidural block by observing bilateral motor response in the legs at 0.3 mA. In the third patient, intravascular placement was suspected and confirmed by failure to obliterate the motor response despite repeated local anesthetic injection. CONCLUSION: The new test provides objective information in managing epidural catheters when their position is uncertain.     

Encircling guidewire facilitates complete excision of image-localized breast lesions

BACKGROUND: An innovative encircling guidewire defines three sides of a target lesion with a single puncture to achieve negative margins. METHODS: Twenty-five patients requiring image-guided surgery were localized with an encircling guidewire. Although the deployed wire is circular, it is straight when placed, using a straight outer needle. After image-guided placement of the wire around the lesion, all patients underwent standard surgical excision. Each patient was categorized by proper localization of the target lesion, presence of negative margins, closest margin, and need for reexcision. RESULTS: The circlewire wire identified the target lesion in all cases. There were no complications relative to either version of the leading tip on the guidewire. Negative margins were achieved in all pure invasive ductal carcinomas. Positive margins were found in all 3 patients with extensive noncalcified in-situ disease and 1 patient with multifocal invasive lobular carcinoma. CONCLUSIONS: An innovative encircling localizing guidewire device gives the surgeon a new option to completely remove a nonpalpable breast lesion.     

201 combined spinal-epidurals for anaesthesia using a separate needle technique

BACKGROUND AND OBJECTIVE: Combined spinal-epidural (CSE) anaesthesia may be performed using separate needles or by passing the spinal needle through an epidural needle. The latter technique requires that subarachnoid block is performed before the epidural catheter is placed. This paper examines a series of 201 consecutive CSEs performed with a novel separate needle technique, designed to avoid potential and actual problems associated with the CSE technique. METHODS: The CSE technique involved placement of the spinal needle in the subarachnoid space, followed by replacement of the spinal needle stylet. The epidural catheter was then positioned separately before returning to the spinal needle and injecting the subarachnoid drug. RESULTS: The technique had a high technical success rate. Both needles were successfully placed in 200 (99.5%) cases. Spinal anaesthesia was successful in all cases. The epidural catheter was used in 179 cases and failure of the epidural occurred in 2 (1.1%) cases. Paraesthesia, inability to advance the epidural catheter or blood in the epidural catheter occurred in 31 (15.4%) and necessitated immediate replacement of the epidural catheter in 14 (7%) cases. Postoperatively, typical post-dural puncture headache was reported by one patient (0.5%) and mild backache by four (2%). There were no neurological complications. CONCLUSIONS: This method of CSE anaesthesia can be associated with high success and low complication rates.     

Long-term central venous catheters: size and location do matter

BACKGROUND: Right or left side of placement for subclavian vein catheterization for placement of long-term central catheters and size of the catheters has not been analyzed completely. METHODS: The records of 502 consecutive long-term central venous catheters placed in patients while in the operating room over a 1-year period were reviewed and 230 subclavian vein tunneled catheters were analyzed. Technical difficulties in placing the catheters were defined as arterial puncture, guidewire malposition, catheter malposition, need to switch site of access, sheath difficulty, and inability to place the catheter. RESULTS: Three complications were identified (1%) and technical difficulties occurred in 15% of the patients. More difficulty was associated with the insertion of larger triple-lumen catheters than smaller single-lumen catheters (31% vs. 11%, respectively; P < .009). Right subclavian placement was associated with a 24.4% technical difficulty rate versus a 10.4% technical difficulty rate for left subclavian placement (P < .005). CONCLUSIONS: This study supports placing the smallest catheter necessary via the left subclavian vein.     

Risk assessment of hemorrhagic complications associated with nonsteroidal antiinflammatory medications in ambulatory pain clinic patients undergoing epidural steroid injection

We prospectively studied 1035 individuals undergoing 1214 epidural steroid injections to determine the risk of hemorrhagic complications. A history of bruising or bleeding was present in 176 (15%) patients. A platelet count was assessed in 77 patients before the epidural steroid injection; none was less than 100 x 10(9)/L. Nonsteroidal antiinflammatory drugs (NSAIDs) were reported by 383 (32%) patients, including 34 patients on multiple medications. Aspirin was the most common NSAID and was noted by 158 patients, including 104 patients on 325 mg or less per day. There were no spinal hematomas (major hemorrhagic complications). Blood was noted during needle or catheter placement in 63 (5.2%) patients (minor hemorrhagic complications). NSAIDs did not increase the frequency of minor hemorrhagic complications. However, increased age, needle gauge, needle approach, needle insertion at multiple interspaces, number of needle passes, volume of injectant, and accidental dural puncture were all significant risk factors for minor hemorrhagic complications. There were 42 patients with new neurologic symptoms or worsening of preexisting complaints that persisted more than 24 h after injection; median duration of the symptoms was 3 days (range, 1-20 days). Our results confirm those of previous studies performed in obstetric and surgical populations that document the safety of neuraxial techniques in patients receiving NSAIDs. We conclude that epidural steroid injection is safe in patients receiving aspirin-like antiplatelet medications. Minor worsening of neurologic function may occur after epidural steroid injection and must be differentiated from etiologies requiring intervention. IMPLICATIONS: Previous studies performed in obstetric and surgical populations have demonstrated that antiplatelet therapy does not increase the risk of spinal hematoma associated with spinal or epidural anesthesia and analgesia. We confirm the safety of epidural steroid injection in patients receiving aspirin-like medications.     

腰穿置管持续引流在神经外科患者中的应用

目的探讨腰穿置管引流在神经外科各种疾病中的辅助治疗作用。方法对采用腰穿置管引流方法的46例患者进行回顾性研究,观察其疗效及并发症情况。结果所有脑脊液漏患者除一例需手术修补漏口外,余32例患者漏口均自行愈合。颅内感染患者3例中有2例感染得到控制。蛛网膜下腔出血和脑室内出血患者10例经此法引流血性脑脊液后,仅有2例出现脑积水,无硬脊膜外血肿、感染等严重并发症。结论腰穿置管引流具有操作简便、安全可靠、创伤小、效果确切、并发症少等优点,是神经外科一种有效的辅助治疗方法。     

Influence of orientations of guidewire tip on the placement of subclavian venous catheters

BACKGROUND: The role of a J-type guidewire tip has been known to prevent vascular or cardiac wall damage. We hypothesized that the course of the guidewire may be influenced by the initial orientations of the J-type guidewire tip during the subclavian approach. The purpose of this study was to investigate the influence of the direction of the needle bevel and J-wire tip on successful placement of subclavian catheters. METHODS: A total of 140 adult patients of either sex were studied. Patients were randomly divided by the direction of the needle bevel (neutral vs. downward) and the direction of the J-wire tip (upward vs. downward). Under general anesthesia, right infraclavicular subclavian catheterization was attempted using the Seldinger technique. RESULTS: There was no statistically significant difference among the successful and unsuccessful placements in relation to factors including sex, body mass index, and needle bevel direction. The success rate was high when the J-wire tip was directed downward (P = 0.001). CONCLUSION: These data suggest that the orientation of the J-wire tip downward can increase successful placement rates of right subclavian venous catheterization.     

Extradural and subarachnoid catheterization using the Seldinger technique

The Seldinger technique was developed using a plastic introducer through which introduction and manipulations of a silicone spinal catheter, an extradural stimulation lead or a small diameter fibreoptic scope are possible without the risk of damage to the vulnerable devices. It is not intended as a replacement of the standard technique of introducing a spinal catheter through a Tuohy needle in general anaesthetic practice. Silicone spinal catheters and stimulation leads are used for long-term therapy in intractable chronic pain and spasticity. A fibreoptic scope is used for endoscopic examination of the subarachnoid or extradural space. Using a standard Tuohy needle the soft silicone extradural lead can be damaged easily by manipulations during insertion. For this reason the manufacturer modified the Tuohy needle for extradural silicone lead introduction. The disadvantages of this modified Tuohy needle are: first, difficulty in localization of the extradural space, second, the needle is unsuitable for a subarachnoid catheter or introduction of a fibreoptic scope. The Seldinger technique was performed 25 times in 18 patients, introducing a spinal silicone catheter (n = 14), an extradural silicone stimulation lead (n = 2) or a small diameter fibreoptic endoscope (n = 9). Paraesthesiae caused by neural irritation occurred in awake patients. This did not differ from the technique using a Tuohy needle only. Neural damage or trauma did not occur with the Seldinger technique. The incidence of post-spinal headache was the same for both techniques. No further complications were noted.      

The breaking of an intrathecally-placed epidural catheter during extraction

IMPLICATIONS: Misplacement of an epidural catheter into the subarachnoid space is a recognized complication. However, breakage of an intrathecal epidural catheter during removal presents a dilemma. Appropriate imaging, a neurosurgical consultation, and aggressive surgical exploration and extraction of the retained piece are warranted, even in the asymptomatic patient.     

Tunneled lumbar drain. Technical note

The authors report a simple and rapid procedure for tunneling a lumbar drain subcutaneously to facilitate chronic cerebrospinal fluid (CSF) drainage. A standard lumbar puncture (LP) is performed with a large-bore Tuohy needle (14- to 16-gauge), the drainage catheter is advanced into the subarachnoid space, and the needle is removed. The free Tuohy needle is then passed from a lateral position and brought out through the initial LP site. The free catheter is fed through the needle, and the needle is removed. The drain is attached to an external drainage bag in the usual manner. The authors have found this method particularly useful in some skull base and spinal surgical applications in which longer term continuous CSF drainage is desired.