FOREIGN BODIES, FRAGMENTED

EPIDURAL CATHETER IN
EPIDURAL SPACE

Dr Sugeng Budi Santoso Sp.An, KMN, FIPM

 EPIDURAL CATHETER
• Epidural anesthesia was first
reported by Sicard and Cathelin in
France, in 1901.
• Whereas continuous techniques
were pioneered by Hingson et al.,
Tuohy, Dawkins, and Bromage
established lumbar epidural
anesthesia as the gold standard for
the management of labor pain.
• As these techniques evolved,
undesirable effects became
apparent.
 COMPLICATION OF EPIDURAL
COMMON RARE
• Epidural Hematome • Knotting and broken
• Local Anaesthetic Toxicity
• High Block
• Trauma and Malposition
• Neurological and spinal cord
injury
 BROKEN EPIDURAL CATHETER

• Rarely encountered, important to be considered

• Epidural catheters are usually made of nylon,
polyethylene, polyurethane and polyamide
• Incidence has been reported to be 1/20,000-
1/30,000
 CAUSES
• Cathether length in epidural space
• Compression between the epidural needle and bony
surface
• Degenerative effects of structural alterations
(degenerative osteoarthritis)
• Impairment in catheter flexibility
• Withdrawal of catheter by patient
• Catheter injury by the Tuohy needle
• Breakage of the strengthening wire in the catheter
• Coiling of catheter
 PREVENTION
• Good insertion technique
• Avoid catheter injury
because of the needle
• Maximum length of 5 cm in
epidural space
• Never suture it to the skin
• Do not use excessive force or
tools (forceps)
• Never pull out the catheter
(or pull with the needle)
 METHOD FOR DIFFICULTY IN
EPIDURAL WITHDRAWAL
• Injecting normal saline through the catheter
• Patients should be placed in the same position
during the insertion
• If first attempt failed, the second one can be done
after 30-60 min in lateral position
• Withdrawal by passing the Tuohy needle over the
catheter is not recommended
 IMPORTANT CONSIDERATION
IN WITHDRAWAL

• Not experience pain during the removal of a

catheter
• In case of pain, should assume that it might be
tangled around a nerve root
• Should be removed under direct visualization
(laminectomy)
 EPIDURAL CATHETER MATERIAL
• Nylon or polyurethane catheters were more resistant
than Teflon or polyethylene catheters
• Polyurethane catheters were more resistant than
radiopaque catheters.
• Reinforced 20G catheters safer than 19G catheters
• 20G have a tendency to break at the site of traction
• 19G have a tendency to break at a fixed site near the tip
• As for catheters reinforced with steel coils, they seem to
have a greater tendency to break than non-reinforced
catheters
 EVALUATION
CLINICAL IMAGING EXAM
• Evaluate the patient • X-Ray
• Evaluate the presence of • MRI
neurologic deficits • CT Scan
• Lumbar USG
 MANAGEMENT

• Retained fragments of an epidural catheter usually

asymptomatic
• Fragment removal was not recommended unless
symptomatic
• If the proximal end of the segment is located at or
just beneath the skin, it can be retrieved by gentle
traction through a skin incision
 MANAGEMENT
• Exploratory laminectomy should be done if:
– The patient develops neurologic changes
– The catheter is in the subarachnoid space
– Epidural tip is emerging out of the skin (entry for
infection)
– Reactive epidural mass can cause lumbar stenosis.
• Imaging evaluation after a month to evaluate if there’s
any migration of the broken catheter
• Broken catheter becomes walled off by fibrous tissue
after remaining in the epidural space for about 3 weeks.
THANK YOU