Securing Epidural Catheters

[zzsleepytinizz]

Where I did residency I would secure the epidural catheter using two epidural stat locks; one at the site of insertion, and another on the shoulder. I would then cover the catheter with 4 tegaderms. Where I am currently completing my OB anesthesia fellowship, the anesthesia team use the little sponge that comes in kit, which in my opinion does a pretty crappy job at securing the catheter at the insertion site, followed by one tegaderm and then tons of silk tape. No one even leaves a window. When it comes to remove the catheter approximately 50% of patient's complain of extreme pain with removal of the silk tape. Also, I notice a lot their skin is red and inflamed. I feel like the silk tape is overkill. I really would appreciate any other advice. Unfortunately, the epidural stat locks are not available at my current hospital.

Also, do you loop the epidural on the back? Where I did residency, we would frequently loop the epidural catheter on the back. I continue to do it at my new institution but I have had other attending complain that it is going to get kinked. I have had no issue with kinking. In contrast, they leave approx. 4-6 inches of catheter hanging off the shoulder and since being here (about 3 months) I have seen catheters get stretched underneath patients to the point that they need to be replaced.

---

Members don't see this ad.

 

[NICMAN]

Two of my attendings (both ABA oral board examiners and OB anesthesiologists -- take that for what it's worth) at my residency program only use wide plastic tape reasoning that it will only be in for at most 24 hours--They do take some extra precautions (sterile tegaderm fixed with mastisol) in placenta previa, super morbid obesity, or other epidurals that will be in there longer. Almost every other attendings at our place use tegaderm + Mastisol/benzoin + plastic tape up to the shoulders and safety pin (or plastic tape) through the MRI/NOT AN IV safety yellow label applied to the catheter at the hub pinned or taped to the front of the hospital gown. If the epidural doesn't work after one adjustment pulling it back 3 cm then it comes out and is replaced.

In my opinion there is no need to loop unless it is a TEA and you are going to x-ray it. TEAs at our residency program always uses stat lock with mastisol and tegaderm and wide pink tape as you described, but they almost always stay in for at least 3 days--usually 5 days. We almost never have dislodged catheter issues with statlock/tegaderm/pink tape thoracic epidurals, but my understanding is that this is substantially more expensive than the labor epidural kit without the stat lock.

 

[pgg]

A spring wound Arrow catheter will never, ever kink. Seriously, try tying one in a knot. Then push fluid through it. You’ll see that deliberate knots won’t impede flow at all. Accidental kinks certainly won’t. (For this reason, the practice of tying intrathecal catheters in knots to prevent accidental injection is dumb.)

I do put a small loop near the insertion point, and if the patient is morbidly obese, I will lay them down before securing the catheter, so the shifting mass of flesh doesn’t pull the catheter out of the epidural space.

Everything else is style and doesn’t matter.


Extreme pain when removing tape? Bleh. Sounds like typical OB histrionics. Tape on the back doesn’t hurt with removal unless it removes a layer of skin with it. OB anesthesia is about the most “customer service” centric thing we do, but come on. You just birthed a child. Don’t whine about the tape used to secure your epidural. The tape is off in about 3 seconds. Be a woman. Shut up.

 

[jwk]

Medium/large tegaderm/opsite over insertion site - a loop like PGG says, and either more tegaderm up to the shoulder or "pink tape". NEVER silk tape, sorry. That stuff is nasty and leaves a gooey residue after removed. The tegaderm or pink tape doesn't.

 

[Ezekiel2517]

A couple tips:
1. Use paper tape. There is something about the sweat and/or body heat that turns that paper tape into clay.
2. The paper tape itself should be enough but another tip is when you tape along the 4 sides of the tegaderm at the insertion site, put an extra piece of tape on the bottom side of the square, covering some of the edge of first tape. When the tape or tegaderm does become undone, it almost always is bc that bottom part starts to unravel from patient movement.

 

[Twiggidy]

Extreme pain when removing tape? Bleh. Sounds like typical OB histrionics. Tape on the back doesn’t hurt with removal unless it removes a layer of skin with it. OB anesthesia is about the most “customer service” centric thing we do, but come on. You just birthed a child. Don’t whine about the tape used to secure your epidural. The tape is off in about 3 seconds. Be a woman. Shut up.

Exactly this.....if you sat there and personal held the epidural in place they would complain about lack of privacy during delivery. There certain OB patient popluations there will complain about every little thing. PGG is 1000% correct, OB is customer service more than any other aspect of anesthesia we perform and for me, part of that service is only needing to do a procedure one time.

Insertion
Sponge
Big tegaderm
Silk tape.

Now the window thing is funny to me because they did that at my training program too, but I’ve seen plenty a epidural migrate out under an air pocket in the window, so now I actual tape the tegaderm over with silk tape. Sure it’s a butt load of tape and the nurses even joke that we have equity in 3M but then I also tell the patient, literally, “you only want a needle in the back once, right?”. Since the nurses pull out catheters, how aggressive they are pulling off the tape is up to them....I just want that epidural to STAY IN.

PS- we don’t have stat locks for epidurals at my gig

 

[nimbus]

Vi-drape spray adhesive was the s***. Smelled good too. I miss it.

 

[zzsleepytinizz]

Extreme pain when removing tape? Bleh. Sounds like typical OB histrionics. Tape on the back doesn’t hurt with removal unless it removes a layer of skin with it. OB anesthesia is about the most “customer service” centric thing we do, but come on. You just birthed a child. Don’t whine about the tape used to secure your epidural. The tape is off in about 3 seconds. Be a woman. Shut up.

I had the same response to the first patients who complained to me. I felt like you just had a baby, how bad could taking the tape off be, especially on your back which is not a particularly sensitive area. However, given the number of people who complain about the tape it must be particularly unpleasant. And their skin is red and inflamed. I would switch back using tegaderms, but the tegaderms we used in residency had a white border which stopped it from peeling off the skin, but we don't have those at my current hospital.

 

[facted]

Way overkill. I have taped labor epidural with two small tegaderms at the site and one strip of regular tape over the tegaderms and one strip going up the back. Literally nothing else. I've done this for well over a thousand. I'll come back here and tell you one the first one falls out. It's easy to remove and patients don't really complain of pain.

 

[sleepallday]

well i guess this is one reason to do an OB fellowship...

 

[ethilo]

Mastisol BEFORE test dose.
Small tegederm once mastisol is DRY. VERY DRY.
Take sterile drape down.
Aggressively wipe sweat off. DRY.
Medium tegederm over the small.
1 large tegederm up the back with a loop in the tubing.
We have a white clip that goes around the hub, then pink tape over that with a loop in the tubing covered by the pink tape.

Large ladies I do a second mastisol for the medium tegederm.

DRY.

Never had an issue yet.

 

[Plead the Fifth]

Catheter in - test dose
Mastisol - dry
Sponge - loop catheter around twice
Large tegaderm
Medipore tape over tegaderm and up to shoulder - small window at insertion
Done

 

[zzsleepytinizz]

well i guess this is one reason to do an OB fellowship...

... really?

 

[somedumbDO]

Honestly this matters very little. They stay in almost regardless of what you do for typical ob pt. I use 2 pieces foam tape off to the side of the pt no back tape that's where all the hair is. No t derm, no viadrape all waste of time. When you do over 500 deliveries a month in a community hospital w only one doc on ob you don't have time for all the fuss.

 

[GasPackerGB]

Spring wound arrow cath. Loop. Tegaderm. Silk tape around borders of teggy leaving a window. One long piece of silk tape up the back and to the top of the shoulder. Fast, easy and it works for me.


Sent from my iPhone using SDN mobile

 

[Noyac]

For OB, tegaderm and medipore tape.
For surgical pts going to the floor for a few days, I tunnel the catheter 2-3cm lateral SQ, I use a 16g jellco/angiocath. Pull the catheter off the needle run the needle from the epidural insertion site lateral 3cm and then poke it out of the skin. Then slide the Anglo cath back onto the needle and all the way to the hub exiting at the epidural insertion site. Remove the needle and slip the epidural cath through the Anglo. Now remove the Anglo and you are tunneled. Back to standard dressing of choice.

 

[drmwvr]

OR staff opens too many of these on nearly every case. We take them and cut them into 2" segments and use them to tape epidural catheters after insertion dressing of choice. As long as the skin is dry, it works very well.

 

[Modanq]

Anyone tunnel the catheter...

 

[Psai]

Anyone tunnel the catheter...

U doing ir or something

 

[Modanq]

U doing ir or something

Ive seen folks pass touhy retrograde through skin to where epidural catheter is coming out of skin, thread catheter though touhy needle and then remove touhy needle....Ive done it once in a very obese pt who was def going to labor for 3 days and then fail to section.

 

[deleted162650]

Good Lord some of you send more time taping than I do placing the epidural in the first place. Bottom line is, I don't really care how my partners secure their catheters, but PLEASE PLEASE leave a window at the insertion site. Nothing chaps my ass like getting called to trouble shoot an epidural I inherited only to find a psychedelic asterisk of tape covering the back. Did the cath get dislodged? Do I have some room to pull it back? I don't know - I can't F'in see it!!!

The other great thing about a tegaderm window at the insertion site is that you can pinch the cath through the tegaderm and pull it back a centimeter or two without removing the dressing or breaking sterility.

I used to just roll with benzoin, medium tegaderm over the insertion site (with a U in the cath to provide some give if it gets snagged on something), and a strip of 2" plastic tape up to the shoulder. Since I no longer have easy access to benzoin, I go with the same medium tegaderm at the site, and then a 8"x12" MegaDerm over the top. I always tell patients that we don't charge for the waxing/exfoliation when the dressing comes off. It's free and included in the new mom spa package.

 

[Noyac]

Good Lord some of you send more time taping than I do placing the epidural in the first place. Bottom line is, I don't really care how my partners secure their catheters, but PLEASE PLEASE leave a window at the insertion site. Nothing chaps my ass like getting called to trouble shoot an epidural I inherited only to find a psychedelic asterisk of tape covering the back. Did the cath get dislodged? Do I have some room to pull it back? I don't know - I can't F'in see it!!!

The other great thing about a tegaderm window at the insertion site is that you can pinch the cath through the tegaderm and pull it back a centimeter or two without removing the dressing or breaking sterility.

I used to just roll with benzoin, medium tegaderm over the insertion site (with a U in the cath to provide some give if it gets snagged on something), and a strip of 2" plastic tape up to the shoulder. Since I no longer have easy access to benzoin, I go with the same medium tegaderm at the site, and then a 8"x12" MegaDerm over the top. I always tell patients that we don't charge for the waxing/exfoliation when the dressing comes off. It's free and included in the new mom spa package.

I could care less where the catheter is at the skin compared to where it was at placement. It either works or it doesn’t. If it doesn’t I pull and replace. That saves me a second call to trouble shoot again.

 

[Urzuz]

Two of my attendings (both ABA oral board examiners and OB anesthesiologists -- take that for what it's worth)

So you mean to say that you can count the number of epidurals placed by both of them in the last three decades on one hand?

 

[psychbender]

No one just puts tegaderms at the site, and over the catheter, up the back? In non-sweaty, moving patients, I've seen less edge-curling and dressing removal with this, than with taping over the borders with silk tape. Then again, I don't do OB anymore, so my opinion is not terribly valid.

 

[BobBarker]

If you are serious about getting it to stay, you should probably do one of the two ways we do it for stim trials.

Option 1: sew it
Option 2: mastisol, then steristrip sandwich running lengthwise on both sides of the catheter, then a steristrip on each side at the base of the cath running horizontal, loop, tegaderm.

Option 2 sounds complicated but isn’t and the catheters don’t move.

 

[AdmiralChz]

I used to just roll with benzoin, medium tegaderm over the insertion site (with a U in the cath to provide some give if it gets snagged on something), and a strip of 2" plastic tape up to the shoulder. Since I no longer have easy access to benzoin, I go with the same medium tegaderm at the site, and then a 8"x12" MegaDerm over the top. I always tell patients that we don't charge for the waxing/exfoliation when the dressing comes off. It's free and included in the new mom spa package.

Exactly what I do, and I've never had or seen a catheter migrate except when the mother is log rolling around like a crazy person in the bed. And we have some gigantic women.

I'm honestly very surprised this has sparked a solid discussion, I don't think I've ever thought about this as a major problem?