BROKEN EPIDURAL CATHETER

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nitroglycerine

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Hello. This question was asked by someone before. 36 weeks pregnant, expecting a labor epidural, saying had an epidural catheter broken in her back many years ago and was not retrieved. no other history available and presumably asymptomatic. What would be a reasonable approach? my colleagues say "Just do it and if something happens it's your fault".
Thanks.

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Hello. This question was asked by someone before. 36 weeks pregnant, expecting a labor epidural, saying had an epidural catheter broken in her back many years ago and was not retrieved. no other history available and presumably asymptomatic. What would be a reasonable approach? my colleagues say "Just do it and if something happens it's your fault".
Thanks.

Broken catheter seems like a one off thing (maybe someone was pulling too hard and forceful) and shouldn't increase risk for it happening again
 
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It's a foreign body in the epidural space. What does 'broken' even mean? 1 cm worth? 6? Adhesions and scarring could be a set up for a spotty block at least and a wet tap at worst. Would want to know at least what level to avoid potentially snaring whatever is in there.
 
This sounds like trouble to me and it is conceivable that you might be blamed for any complication that might happen. I wouldn't do it unless I have an MRI showing where exactly the foreign body is. This should have been planned ahead of time.
 
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Labor epidural is "elective", so unless this had been preplanned with investigations such as MRI, discussion of risks possibly with neurosurgery etc. I would steer clear and offer alternate anaglesia. As a foreign body, I would think there is at least increased risk of infection especially if you happened to go in blind and end up at or very near the old catheter. For a C/S I would do spinal given the risk/benefit vs GA.
 
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Thank you, everyone. I feel more like Plankton, everyone else here says "probably ok, we will order the ultrasound because she is pregnant and the catheter could have a wire in it so no MRI or CT or even AP/lateral lumbar x-ray'. They realize that the information will likely be limited and maybe useless. I am planning to talk to the neurosurgeons too. Would probably refer her for a formal neurosurgery consult after delivery.
 
Thank you, everyone. I feel more like Plankton, everyone else here says "probably ok, we will order the ultrasound because she is pregnant and the catheter could have a wire in it so no MRI or CT or even AP/lateral lumbar x-ray'. They realize that the information will likely be limited and maybe useless. I am planning to talk to the neurosurgeons too. Would probably refer her for a formal neurosurgery consult after delivery.

Whole situation sounds FUBAR.
 
Spring wound epidural cath is ok for MRI as long as it’s not one of the new super high tesla magnet machines.
 
Spring wound epidural cath is ok for MRI as long as it’s not one of the new super high tesla magnet machines.
Our is 1,5 Tesla. Is it super high? Will discuss it with our radiologist today.
 
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I would guess the broken piece is outside of the epidural space. Previous doc probably got a false loss, tried to ram catheter somewhere, got stuck, and forcefully sheared catheter while trying to pull it back out. I would do epidural after long chat with patient.
 
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I think 1.5 should be ok. The newer ones are 2-3T. Definitely consult with rads though.
I'd give the OP $1 to just walk up to the MRI with an epidural catheter in his hand to see what happens.

I'd guess absolutely nothing. Not sure what alloy they use to make the springs but it's surely some variety of stainless steel. Some stainless alloys are magnetic but 316 is the usual "medical" stainless steel and it's nonmagnetic. That said funny things happen to materials in super powerful fields.

OP should go talk to the radiologists and inspect a machine with a catheter in his pocket and then report back.
 
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I'd give the OP $1 to just walk up to the MRI with an epidural catheter in his hand to see what happens.

I'd guess absolutely nothing. Not sure what alloy they use to make the springs but it's surely some variety of stainless steel. Some stainless alloys are magnetic but 316 is the usual "medical" stainless steel and it's nonmagnetic. That said funny things happen to materials in super powerful fields.

OP should go talk to the radiologists and inspect a machine with a catheter in his pocket and then report back.

If I remember correctly, the concern was that the spring coil could heat up, not that it would move.

I’m on OB call tonight. If it’s slow and I get bored, I just might walk over to the MRI with an arrow epidural cath. Do you Venmo?
 
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If I remember correctly, the concern was that the spring coil could heat up, not that it would move.

I’m on OB call tonight. If it’s slow and I get bored, I just might walk over to the MRI with an arrow epidural cath. Do you Venmo?
Ah, didn't think of heat from an induced current as it moves through the field.

Be sure to crawl through the scanner a couple times to see if it gets hot. Venmo is good.
 
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So, digging around on the interwebs I found this: Epidural Catheter Design | Anesthesiology | American Society of Anesthesiologists

Which says the following:

The catheter bodies are radiopaque; however, one manufacturer considers its catheter “magnetic-resonance-conditional” based on nonclinical testing, which allows for use under specific conditions (i.e., a static magnetic field of 3-Tesla or less, a maximum spatial gradient magnetic field of 720-Gauss/centimeter or less, and a transmit/receive radio frequency head coil).

I took an Arrow flex-tip cath down to our 3T MRI. Holding it next to the magnet resulted in no noticeable pull. I put it against the side of the magnet and it did not stick. I then dangled the catheter in the opening of the tube, and the end did curve and pull into the tube. It was weak, not enough to feel, but there was clearly an effect. Both ends behaved similarly. I asked the tech if it would heat up if left in there long enough. She said she would expect it to heat up during a scan due to the pulsed RF. Do with that info what you will.

Now, @pgg , where’s my money?

 
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So, digging around on the interwebs I found this: Epidural Catheter Design | Anesthesiology | American Society of Anesthesiologists

Which says the following:

The catheter bodies are radiopaque; however, one manufacturer considers its catheter “magnetic-resonance-conditional” based on nonclinical testing, which allows for use under specific conditions (i.e., a static magnetic field of 3-Tesla or less, a maximum spatial gradient magnetic field of 720-Gauss/centimeter or less, and a transmit/receive radio frequency head coil).

I took an Arrow flex-tip cath down to our 3T MRI. Holding it next to the magnet resulted in no noticeable pull. I put it against the side of the magnet and it did not stick. I then dangled the catheter in the opening of the tube, and the end did curve and pull into the tube. It was weak, not enough to feel, but there was clearly an effect. Both ends behaved similarly. I asked the tech if it would heat up if left in there long enough. She said she would expect it to heat up during a scan due to the pulsed RF. Do with that info what you will.

Now, @pgg , where’s my money?

This is awesome.
 
Probably not. I was thinking more in terms of the referral after delivery so it would be nice to discuss the labor epidural with the same neurosurgeon.
 
As a neurosurgeon I would be happy to remove it but I'm not sure if it has been years without an infection that it is worth removing.
It looks like the common approach is to try to locate the broken piece with imaging when not pregnant and not touch it unless it causes symptoms or is in some location where it is dangerous to leave it. If it has been asymptomatic for many years and the patient did not bother to have it investigated and she is almost term do you think it is reasonable to try the labour epidural as she is requesting? I also asked this question on our SDN's neurosurgery forum. If you wanted to locate it before she delivers what imaging would you use? Ultrasound? AP and lateral lumbar x-ray? MRI(the catheter may have a wire in it). Thanks.
 
So, digging around on the interwebs I found this: Epidural Catheter Design | Anesthesiology | American Society of Anesthesiologists

Which says the following:

The catheter bodies are radiopaque; however, one manufacturer considers its catheter “magnetic-resonance-conditional” based on nonclinical testing, which allows for use under specific conditions (i.e., a static magnetic field of 3-Tesla or less, a maximum spatial gradient magnetic field of 720-Gauss/centimeter or less, and a transmit/receive radio frequency head coil).

I took an Arrow flex-tip cath down to our 3T MRI. Holding it next to the magnet resulted in no noticeable pull. I put it against the side of the magnet and it did not stick. I then dangled the catheter in the opening of the tube, and the end did curve and pull into the tube. It was weak, not enough to feel, but there was clearly an effect. Both ends behaved similarly. I asked the tech if it would heat up if left in there long enough. She said she would expect it to heat up during a scan due to the pulsed RF. Do with that info what you will.

Now, @pgg , where’s my money?


Thanks, good to know it. I am still waiting in the neurosurgeons and the Rads to get back to me.
 
You need to find out who let this lady leave the hospital with no imaging after her last delivery knowing there was a piece of catheter still in her back and punch them square in the testicles.
 
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Now, @pgg , where’s my money?
Post your bank name, login and password here and I'll transfer it directly.

I've used my moderator powers to toggle the thread privacy settings so your account info will just appear as ****** to other people.
 
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It looks like the common approach is to try to locate the broken piece with imaging when not pregnant and not touch it unless it causes symptoms or is in some location where it is dangerous to leave it. If it has been asymptomatic for many years and the patient did not bother to have it investigated and she is almost term do you think it is reasonable to try the labour epidural as she is requesting? I also asked this question on our SDN's neurosurgery forum. If you wanted to locate it before she delivers what imaging would you use? Ultrasound? AP and lateral lumbar x-ray? MRI(the catheter may have a wire in it). Thanks.

I would think you could see in on Lat Lumber spine Xray.

Even if I couldnt see it I would still do the procedure is thats what the patient wants and risks are known.

NOT having a labor epidural is a big deal for women, I would urge those who are balking at this to consider that
 
You need to find out who let this lady leave the hospital with no imaging after her last delivery knowing there was a piece of catheter still in her back and punch them square in the testicles.
What if it was a girl?
 
I would think you could see in on Lat Lumber spine Xray.

Even if I couldnt see it I would still do the procedure is thats what the patient wants and risks are known.

NOT having a labor epidural is a big deal for women, I would urge those who are balking at this to consider that
It is a big deal. What risks specifically would you discuss with her on top of the usual ones like PDPH and the epidural hematoma/abscess?
 
It is a big deal. What risks specifically would you discuss with her on top of the usual ones like PDPH and the epidural hematoma/abscess?

"Because of the possibility of the old broken catheter in the same area I'll be doing the procedure, there are some increased risks with this procedure. I'm happy to do the procedure but I just wanted you to understand the risks and be on the same page. It's possible that the pain relief from the epidural is less than usual due to a patch created by the old catheter i your epidural space. It' s possible the feel of the tissue in the area has changed and that my needle will enter the spinal space accidentally maybe leading to a HA. Rare complications like infection are also possible but I would not offer this to you if I did not think it would be safe and have a good chance of working well. Before I proceed I just wanted you and me to be on the same page because I want to do what you want me to do"

Be honest. Dont scare them with 1:10000000 side effects. Empower the patient. It's their decision. Not your's because its "not worth it"

Any "old catheter" is likely in the SubQ tissue and its not going to be an issue significant enough to deny her her epidural.
 
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