Epidural placement with a broken tip !

[Cookie]

Just wondering if any of you guys came across this situation. A pt requesting an epidural for labor who had an epidural placed in the past with the broken catheter tip still in her back ! Is it safe to do another epidural ? would a spinal be safer ? thanks

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[rsgillmd]

I haven't run across it, but I can't imagine why it would not be safe. Unless you are trying to say you are concerned about another tip breaking. I've only heard of one tip breaking, and it was suspected to be due to poor technique in inserting the catheter.

I'm guessing the catheter tip will probably be walled off by fibrosis anyway.

 

[Idiopathic]

I wouldnt let this alter your practice, but I would have a heightened sense of awareness for difficult catheter placement or unanticipated symptoms

 

[pjl]

Based on my discussions with some very experienced people (none of which have ever run into this situation) the proper thing to do for this is to insert another epidural if the patient requests. The common thought was that if you knew the level of the previous placement, go to a different level, but that it probably doesn't matter.

 

[Cookie]

Is there a risk of dislodging the old catheter's tip or pushing it deeper with the epidural needle ?

 

[lobelsteve]

Is there a risk of dislodging the old catheter's tip or pushing it deeper with the epidural needle ?

If you were using fluoro and wanted to hit it, that would be a challenge, but going in for L&D you are highly unlikely to get near the tip. And if so, it is in the epidural space. No air in there, just fat, vessels, and nerves. If it is partly calcified and scarred in, then you may have difficulty getting passed the foreign body cath tip with your new catheter. The medication will flow around it regardless.

 

[Sergio99]

...The common thought was that if you knew the level of the previous placement, go to a different level, but that it probably doesn't matter.

Even if you knew the level of the previous placement, you would have no way of knowing the location of the broken tip, unless you take an X-Ray and hope the catheter is opaque enough to show. Besides, the chances of you hitting it are extremely remote, and even if you did touch it, most probably nothing would happen. However, being prudent requires that you tell the patient all your concerns, emphasizing the low likelihood that any of them come to pass, and see if she still wants it.

 

[RxBoy]

Just wondering if any of you guys came across this situation. A pt requesting an epidural for labor who had an epidural placed in the past with the broken catheter tip still in her back ! Is it safe to do another epidural ? would a spinal be safer ? thanks

I had a very similar story from a pt on the OB floor for a planned c/s. Patient was 300+ pounds, 4th grade education at best, gestational diabetes, no neck, decreased neck mobility, MP IV, poor mouth opening.... Top it off she refused to undergo an AFI.

She said she had chronic back pain because she was sure "an epidural needle broke in her back", (not because she was morbidly obese or multiple previous pregnancies). Did a quick EMR background check on the patient. She had a previous lumbar MRI for this "broken needle" ordered by her PCP. Negative for foreign body. Turns out, she was your run of the mill crazy patient. Could convince her for a repeat epidural but could not convince her for the life of me for an AFI.

Wrote extensive documentation on patients refusal for AFI even if it meant death. Harpooned her with a 15 cm tuohy, threaded a cath without issue, difficult intubation cart on stand by, titrated chloroprocaine throughout case..... Did a 4 hr section with an awake crazy lady, called it a day.

 

[Idiopathic]

im not sure i would have done an MRI to check for a broken Touhy in the back although it could have been therapeutic i suppose

 

[nap$ter]

I had a very similar story from a pt on the OB floor for a planned c/s. Patient was 300+ pounds, 4th grade education at best, gestational diabetes, no neck, decreased neck mobility, MP IV, poor mouth opening.... Top it off she refused to undergo an AFI.

She said she had chronic back pain because she was sure "an epidural needle broke in her back", (not because she was morbidly obese or multiple previous pregnancies). Did a quick EMR background check on the patient. She had a previous lumbar MRI for this "broken needle" ordered by her PCP. Negative for foreign body. Turns out, she was your run of the mill crazy patient. Could convince her for a repeat epidural but could not convince her for the life of me for an AFI.

Wrote extensive documentation on patients refusal for AFI even if it meant death. Harpooned her with a 15 cm tuohy, threaded a cath without issue, difficult intubation cart on stand by, titrated chloroprocaine throughout case..... Did a 4 hr section with an awake crazy lady, called it a day.

why did you try to convince her for AFI? epidural would have been my first pitch...

 

[CambieMD]

We tend to refer to patients as being "crazy." I think that all of us are a little peculiar in our own way.

RA was designed for the patient that you are describing. Do you really think that the patient that you just described would tolerate an AFI. You would be asking for problems.

I am curious about your choice of LA. Did you select a LA with a short half life because you were afraid of a high block.

Cambie

 

[Idiopathic]

We tend to refer to patients as being "crazy." I think that all of us are a little peculiar in our own way.

RA was designed for the patient that you are describing. Do you really think that the patient that you just described would tolerate an AFI. You would be asking for problems.

I am curious about your choice of LA. Did you select a LA with a short half life because you were afraid of a high block.

Cambie

thats my thinking

honestly i would have put an intrathecal catheter in this patient, and i rarely go that route electively

couple a difficult airway with the possibility of significant scar tissue/fibrosis near or in the epidural space and i wouldnt have trusted an epidural catheter

 

[Arch Guillotti]

I had a very similar story from a pt on the OB floor for a planned c/s. Patient was 300+ pounds, 4th grade education at best, gestational diabetes, no neck, decreased neck mobility, MP IV, poor mouth opening.... Top it off she refused to undergo an AFI.

She said she had chronic back pain because she was sure "an epidural needle broke in her back", (not because she was morbidly obese or multiple previous pregnancies). Did a quick EMR background check on the patient. She had a previous lumbar MRI for this "broken needle" ordered by her PCP. Negative for foreign body. Turns out, she was your run of the mill crazy patient. Could convince her for a repeat epidural but could not convince her for the life of me for an AFI.

Wrote extensive documentation on patients refusal for AFI even if it meant death. Harpooned her with a 15 cm tuohy, threaded a cath without issue, difficult intubation cart on stand by, titrated chloroprocaine throughout case..... Did a 4 hr section with an awake crazy lady, called it a day.

I am a little confused about your emphasis on awake fiberoptic intubation. Why did you press it so hard? If she truly had a 4th grade education I doubt she understood what you were trying to explain it to her.

I would have saved that talk for when the epidural failed and you had to come up with plan B if GETA is the way you decided to go.

 

[Idiopathic]

we occasionally tell our obstetric team "there will be no crash-section with this patient" and this would be that patient

 

[Arch Guillotti]

we occasionally tell our obstetric team "there will be no crash-section with this patient" and this would be that patient

I tell them that too on occasion. I am just a little confused why you would go to such lengths about AFOI when LEA is a viable option (or intrathecal catheter).

 

[Idiopathic]

sometimes if im trying to "convince" people that an epidural is a good idea ill discuss AFI for emergent cesarean, but usually only in those who look as this lady does

 

[RxBoy]

I tell them that too on occasion. I am just a little confused why you would go to such lengths about AFOI when LEA is a viable option (or intrathecal catheter).

THere are 2 ways to approach this situation.

1) More liberal approach... Go regional and hope for no total spinal from either interthecal catheter or possible migration of epidural intrathecally causing total spinal during bolus (which I've seen) ignoring the airway. But if you do cause one and can't intubate, you will have a dead patient and a baby due to her known difficult intubation. Even if you intubate, a big risk for aspiration during intubation.

2) Conservative approach.... Deal with the airway from the get go with AFI, secure it, anesthetize her, deliver the baby.

Side story:
I've done option #1 before for a different case. It was a TKA knee of a female patient with a BMI of 62. Patient had baseline CO2 narcosis and barely oriented during pre-op. Slept sitting up because of severe sleep apnea. Orthopods assured me it wouldn't take longer than 2 hours max. My attendings plan opted for single shot spinal with bupivacaine which I did. On the table, patient in and out of sleep apnea cycles every couple minutes with absolutely no sedatives on board. Had to physically stimulate patient to wake up and breath because sat's drop to mid 80's. 3 hours into case, orthopods no where near finishing spinal wearing off. Patient starts screaming. Hit her with 25 mg ketamine IV and call for attending overhead. By the time he got there, patient no longer breathing and sats dropping <70. Learned the hard way that ketamine does not always preserve SV. Tried to bag mask... 0 ventilation. Tried LMA, no ventilation. Called for ENT on standby and glidescope intraop. Put glidescope in.... Grade 3 view even with glidescope. Used a bougie for a blind intubation and luckily intubated. Used fiberoptic to insure tracheal intubation. Secured airway but it took peak pressures of 50 to ventilate her. No bronchospasm.... Just to much weight on that damn chest. After 5 minutes of hand ventilating with pop off valve nearly closed, got the sats back up in lower 90's. Pushed 6 of versed and hand ventilated for rest of case. Mechanical vent wasn't strong enough to ventilate patient. Once in PACU, put her on an ICU vent which was able to ventilate her much easier and got her back up to 99. Patient woke up, F/C, SV, pulling 500 ml TVs. Extubated her and put her on CPAP. Talked to her the next day, she didn't remember a thing.

Because I got burned, I will never approach a difficult intubation with the easy way out. Better to have an uncomfortable patient then a dead one.

 

[lord_jeebus]

THere are 2 ways to approach this situation.

1) More liberal approach... Go regional and hope for no total spinal from either interthecal catheter or possible migration of epidural intrathecally causing total spinal during bolus (which I've seen) ignoring the airway. But if you do cause one and can't intubate, you will have a dead patient and a baby due to her known difficult intubation. Even if you intubate, a big risk for aspiration during intubation.

2) Conservative approach.... Deal with the airway from the get go with AFI, secure it, anesthetize her, deliver the baby.

I like #3 - intentional intrathecal catheter, titrated slowly to desired level.

 

[RxBoy]

We tend to refer to patients as being "crazy." I think that all of us are a little peculiar in our own way.

RA was designed for the patient that you are describing. Do you really think that the patient that you just described would tolerate an AFI. You would be asking for problems.

I am curious about your choice of LA. Did you select a LA with a short half life because you were afraid of a high block.

Cambie

Precisely. Thanks to Hoffman degradation, I'm not too worried about intravascular migration. Thanks to fast onset, I can aspirate and then bolus 10% dose to assure not intrathecal. If no clinical effect within a couple minutes, I can push the remaining 90%. Had to re-bolus twice during the section.

 

[RxBoy]

I like #3 - intentional intrathecal catheter, titrated slowly to desired level.

Yeah that would been my next alternative. CSE was out of the question because we don't have harpoon/CSE kit. Not sure if they even make one.

 

[OB1🤙]

It was a TKA knee of a female patient with a BMI of 62.... Orthopods assured me it wouldn't take longer than 2 hours max. My attendings plan opted for single shot spinal with bupivacaine which I did.

Yeesh. I know this wasn't your plan but a single shot spinal in an airway disaster pt for a total knee is asking for trouble, regardless of how confident your orthopods are. I'd CSE this pt, but an intrathecal catheter is perfectly reasonable as well.

If for some reason I had to do a single shot, I'd probably do it with tetracaine to make damn sure it would serve for the duration of the case.

Edit: I see you don't have a spinal needle that can fit through the harpoon. In that case, IT catheter or tetracaine.

 

[RxBoy]

Yeesh. I know this wasn't your plan but a single shot spinal in an airway disaster pt for a total knee is asking for trouble, regardless of how confident your orthopods are. I'd CSE this pt, but an intrathecal catheter is perfectly reasonable as well.

If for some reason I had to do a single shot, I'd probably do it with tetracaine to make damn sure it would serve for the duration of the case.

Edit: I see you don't have a spinal needle that can fit through the harpoon. In that case, IT catheter or tetracaine.

Yeah but tetracaine/bupivacaine not that much different. Maybe tetracaine + epi. I think an intentional intrathecal catheter would of been my next best bet after AFI. Hind sight is always 20/20. In any case you better believe I would of pulled that sucker out myself in PACU.

Intrathecal catheters for C/S patients are a different story... Our protocol is to leave them in for 24 hours before removing due to decreased risk of HA. Leaving an intrathecal catheter always makes me nervous even if I properly label it and let the nurses/attendings/CRNAs/residents know. Heard about a case from an attending at a different institution near ours where the intrathecal catheter was left in. At night... a SRNA/CRNA was paged about s/p c/s pain. The SRNA pushed 10 cc of 1% lido while the CRNA "supervised". Patient had a total spinal. Patient was intubated, and immediately transferred to ICU. The patient was left permanently brain damaged. Makes me quiver to think about. They should just get rid of that stupid 24 hour rule, a HA is the least of my worries.

 

[rsgillmd]

Yeah but tetracaine/bupivacaine not that much different. Maybe tetracaine + epi. I think an intentional intrathecal catheter would of been my next best bet after AFI. Hind sight is always 20/20. In any case you better believe I would of pulled that sucker out myself in PACU.

Intrathecal catheters for C/S patients are a different story... Our protocol is to leave them in for 24 hours before removing due to decreased risk of HA. Leaving an intrathecal catheter always makes me nervous even if I properly label it and let the nurses/attendings/CRNAs/residents know. Heard about a case from an attending at a different institution near ours where the intrathecal catheter was left in. At night... a SRNA/CRNA was paged about s/p c/s pain. The SRNA pushed 10 cc of 1% lido while the CRNA "supervised". Patient had a total spinal. Patient was intubated, and immediately transferred to ICU. The patient was left permanently brain damaged. Makes me quiver to think about. They should just get rid of that stupid 24 hour rule, a HA is the least of my worries.

If you are that scared, besides labeling it very well, tape the heck out of it such that it takes a conscious effort to inject through there.

Luckily in my residency program we only had two CRNAs: one in the evenings, and one in the days that worked in ASU. With good communication between residents, we never had any such incidents.

At my current program, most of the CRNAs are too scared to handle intrathecal catheters and they never respond for post-op pain issues. Since most of my colleagues don't like sending patients with catheters to the floor, if I do so I'll remove it myself before I get relieved.

Anyway morbidly obese patients are unlikely to get headaches, even pregnant ones. The textbooks say it, and you can take my word for it. The CRNAs/SRNAs here have gotten plenty of wet taps in the 1.5+ years I've been here, in the vast majority of which they took the needle out and redid an epidural. We rarely have to do a blood patch because the majority of our patients are morbidly obese. There was one obese patient that required a patch, to my knowledge in this time frame. The rest that needed patches have been more normal sized.

 

[Idiopathic]

I've done option #1 before for a different case. It was a TKA knee of a female patient with a BMI of 62. Patient had baseline CO2 narcosis and barely oriented during pre-op. Slept sitting up because of severe sleep apnea. Orthopods assured me it wouldn't take longer than 2 hours max. My attendings plan opted for single shot spinal with bupivacaine which I did. On the table, patient in and out of sleep apnea cycles every couple minutes with absolutely no sedatives on board. Had to physically stimulate patient to wake up and breath because sat's drop to mid 80's. 3 hours into case, orthopods no where near finishing spinal wearing off. Patient starts screaming. Hit her with 25 mg ketamine IV and call for attending overhead. By the time he got there, patient no longer breathing and sats dropping <70. Learned the hard way that ketamine does not always preserve SV. Tried to bag mask... 0 ventilation. Tried LMA, no ventilation. Called for ENT on standby and glidescope intraop. Put glidescope in.... Grade 3 view even with glidescope. Used a bougie for a blind intubation and luckily intubated. Used fiberoptic to insure tracheal intubation. Secured airway but it took peak pressures of 50 to ventilate her. No bronchospasm.... Just to much weight on that damn chest. After 5 minutes of hand ventilating with pop off valve nearly closed, got the sats back up in lower 90's. Pushed 6 of versed and hand ventilated for rest of case. Mechanical vent wasn't strong enough to ventilate patient. Once in PACU, put her on an ICU vent which was able to ventilate her much easier and got her back up to 99. Patient woke up, F/C, SV, pulling 500 ml TVs. Extubated her and put her on CPAP. Talked to her the next day, she didn't remember a thing.

Because I got burned, I will never approach a difficult intubation with the easy way out. Better to have an uncomfortable patient then a dead one.

my opinion, but Im not sure if you got burned as much as you made the wrong decision (probablyattending-guided, but still...) Cant blame the technique when it wasnt a good idea to begin with (see bolded)...after the decision to commit to regional (why no catheter?) you become reactionary; no way around it.

 

[pgg]

Thanks to Hoffman degradation, I'm not too worried about intravascular migration.

Just nitpicking here as your basic point stands, but chloroprocaine is metabolized by plasma pseudocholinesterases. Cis-atracurium goes by Hofmann.