Securing epidural

[Lecithin5]

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For the life of me I cannot consistently secure specifically thoracic epidurals so that on day 4 or 5 they don’t migrate out. Not that it happens a lot, but it happens enough where it is annoying. I’ve tried every method out there. Every type of skin glue and tape etc. Now I know that sometimes it is inevitable (ie pt moves etc), but I just wanted to hear what some of you guys do.

 

[jwk]

We secure all ours with Tegaderm or similar clear plastic dressings. It usually takes two large ones to go all the way up the back. Some reinforce that with "pink tape" as well. Our department rounds on these patients every morning, so if it's coming loose, we can always reinforce or replace the dressing if the catheter still appears to be in an appropriate position.

 

[Velefunt]

Tegaderms. Cut rolled edges and reenforce PRN. Re-dress entirely if needed.

 

[dchz]

I don't think the type of tape matters, as long as it's sterile.

The key to securing the catheter, like we do with IVs, is to build in mechanical migration neutralizers (basically loops that tighten when the catheter is pulled - therefore the pulling is translated into the swirl rather than actually pulling the catheter out.

so next time you do it, put a few loops around the puncture site, and another loop around the shoulder where you tape it. That should help.

 

[Maverikk]

Agree with dchz loops help a lot for that inadvertent tug, also dermabond (or whatever skin glue you have), mastisol and steris then tegaderm

Edit: as dipriman says below, disconnections can happen at the where the clip attaches to the catheter. I put one loop around the clip and pretty much wrap the whole clip up to the luer lock in tape. Once had an urgent C-section, asked the nurse to disconnect the catheter and bring the patient straight back. They disconnected by ripping off the clip, one of those times that tests your professionalism just took a deep breath said it's ok it happens and did a spinal, smiled and helped showed the nurses how a luer lock works on an epidural catheter ('it's tricky, these things are hard to figure out if you don't use them everyday') and received a lot of positive feedback.

 

[deleted875186]

Nothing fancy, large tegederm, mastisol, and silk tape around edges and up the back to the shoulder. Loop of catheter at puncture site and once more farther up the back. Haven’t had one come out in a while, with this dressing it’s usually more likely for the hub where the infusion connects to come loose first.

 

[abolt18]

I have had 1 attending who does this, and after the mastisol dried, he actually pulled on the epidural catheter to show how well it was secured and it pulled the patient backward without pulling out the catheter

Start with mastisol on the skin

Fold the catheter so it's flat on the skin and place the first steri strip flat in it so the center of it is at the insertions site.

Fold the opposite way and place the next steri strip effectively sandwiching the epidural catheter.

Voilà you have a catheter that will stay.

Then implement the previously mentioned loops and tegaderms.

 

[dchz]

I have had 1 attending who does this, and after the mastisol dried, he actually pulled on the epidural catheter to show how well it was secured and it pulled the patient backward without pulling out the catheter

Start with mastisol on the skin

Fold the catheter so it's flat on the skin and place the first steri strip flat in it so the center of it is at the insertions site.

Fold the opposite way and place the next steri strip effectively sandwiching the epidural catheter.

Voilà you have a catheter that will stay.

Then implement the previously mentioned loops and tegaderms.

When I walked in this morning and saw that the flag was half-mast, I thought ‘All right, another bureaucrat ate it!'

We need a picture.

Then I found out it was Li'l Sebastian then I thought half-mast was too high.

 

[abolt18]

We need a picture.

Then I found out it was Li'l Sebastian then I thought half-mast was too high.

 

[deleted875186]

I still unfortunately do not understand.

 

[abolt18]

I still unfortunately do not understand.

Blue and green = steri strips
Black = epidural catheter
Tan = skin

I don't know how much more I can say.

 

[vector2]

Blue and green = steri strips
Black = epidural catheter
Tan = skin

I don't know how much more I can say.

When I walked in this morning and saw that the flag was half-mast, I thought ‘All right, another bureaucrat ate it!'

Lol dude, condolences but this might be the worst diagram I’ve ever seen

 

[Triddafa]

For catheters that I really don't want to fall out (like thoracic epidurals) I tunnel them ~4-5cm under the skin, dermabond glue the exit point (after tunnel), do a loop and dermabond that, tegaderm over all that and then use hyperfix all the way to the shoulder. Works great. Tunnelling is the key.

 

[Hork Bajir]

Could you explain how you tunnel them? Does it make the catheter harder to remove? Do you need additional equipment beyond what comes in a standard epidural kit?

My institution recently started using the StatLock device, which I’m a big fan of

 

[deleted162650]

Could you explain how you tunnel them?

Use the Tuohy

 

[abolt18]

Criticism welcome. I spent about 30 seconds on it. Despite it looking terrible, did you understand it? If so, I'll still consider it a success

Lol dude, condolences but this might be the worst diagram I’ve ever seen

 

[dabears505]

How many days do you want it in? 4-5 days seems long enough

 

[Urzuz]

For the life of me I cannot consistently secure specifically thoracic epidurals so that on day 4 or 5 they don’t migrate out. Not that it happens a lot, but it happens enough where it is annoying. I’ve tried every method out there. Every type of skin glue and tape etc. Now I know that sometimes it is inevitable (ie pt moves etc), but I just wanted to hear what some of you guys do.

If a patient is getting up to a chair and/or ambulating, there is no way to guarantee that an epidural will be in the exact same state it was in when you put it in 4-5 days previously. Between the catheter migrating out, the puncture site starting to leak, etc, there is always going to be some degree of chance that it’ll start to become less functional.

The real question is, in what scenario are you keeping epidurals in for over 5 days where they are so critical that the infection risk (and the annoyance of rounding on them every day 🙂) doesn’t prompt you to take it out?

 

[Lecithin5]

If a patient is getting up to a chair and/or ambulating, there is no way to guarantee that an epidural will be in the exact same state it was in when you put it in 4-5 days previously. Between the catheter migrating out, the puncture site starting to leak, etc, there is always going to be some degree of chance that it’ll start to become less functional.

The real question is, in what scenario are you keeping epidurals in for over 5 days where they are so critical that the infection risk (and the annoyance of rounding on them every day 🙂) doesn’t prompt you to take it out?

Agreed- I think ultimately despite all of these methods of securing the catheter (most of which I have tried over the years), the actual insertion site at the skin is where the catheter starts to come out (ie not due to the inadvertent pulling of the catheter distal to the insertion site), no matter how many pieces of Tegaderm or steri-strips or skin glue you use. It’s the friction at the site due to patient movement...

And while not common, there certainly are many times where we (would like to) have epidurals in for longer than 4-5 days- we are at one of the highest volume lung transplant centers in the country, and epidurals can be in for up to a week or so for a variety of different reasons...

 

[woopedazz]

I don't think the type of tape matters, as long as it's sterile.

The key to securing the catheter, like we do with IVs, is to build in mechanical migration neutralizers (basically loops that tighten when the catheter is pulled - therefore the pulling is translated into the swirl rather than actually pulling the catheter out.

so next time you do it, put a few loops around the puncture site, and another loop around the shoulder where you tape it. That should help.

For the interns who don't get it.

 

[dchz]

For the interns who don't get it.

View attachment 308190

Can you teach @abolt18 ??

 

[lobelsteve]

Staples. Swingline, red.

 

[deleted697535]

Well
1 don't do epidurals
2 day 4 or 5 99% should be coming out anyway
3 when putting them on make sure skin is very dry, use warmth of your hand and gentle friction to massage the dressing into the skin almost.
4 line your dressing with paper tape and use alcohol swabs to rub that into the skin again


That's all I do for vast majority of mine and haven't had many problems. Got 7 days off one. Problems are when the person is very fat, very sweaty, hairy or just not a sticky person

 

[DocVapor]

Well
1 don't do epidurals
2 day 4 or 5 99% should be coming out anyway
3 when putting them on make sure skin is very dry, use warmth of your hand and gentle friction to massage the dressing into the skin almost.
4 line your dressing with paper tape and use alcohol swabs to rub that into the skin again


That's all I do for vast majority of mine and haven't had many problems. Got 7 days off one. Problems are when the person is very fat, very sweaty, hairy or just not a sticky person

That's more warm rubbing with gentle friction than I'm willing to do with strangers.

 

[Triddafa]

Could you explain how you tunnel them? Does it make the catheter harder to remove? Do you need additional equipment beyond what comes in a standard epidural kit?

My institution recently started using the StatLock device, which I’m a big fan of

No additional equipment beyond what you normally have. Essentially just put a line of local from the entry point to a few centimeters out. Then, from that point a few centermeters out put your Touhy under the skin and as close to the epidural entry point as possible (without hitting it of course!), then place the catheter in the Touhy and pull it through.

I searched Youtube for an example and these guys seem to do roughly what I'm talking about (in some kind of ghetto ripped sterile drape world haha). I would typically do it a little deeper than the just under the skin they seem to. Also I like to use the cap of the local needle or something else to provide counter traction so you aren't putting your fingers near a Touhy popping out from under the skin.


If you are intentially removing them then it should be just as easy as normal as long as you don't glue the little 'bridge' between the entry point and tunnel entry point. I've seen people do this and it makes it quite tricky to remove.... sort of deliberate I suppose?

 

[deleted875186]

I see. I have done this technique, I can’t tell if the epidural stays any better than just securing it normally.

if you do this you no longer see the markings on the catheter when you go tk round on the patient.

 

[Urzuz]

And while not common, there certainly are many times where we (would like to) have epidurals in for longer than 4-5 days- we are at one of the highest volume lung transplant centers in the country, and epidurals can be in for up to a week or so for a variety of different reasons...

We never used to put epidurals in for lung transplants but I can see how they could facilitate early extubation, reduction in opioids, etc. But to keep an epidural in for a week in an immunocompromised patient with a new pair of lungs seems to be asking for trouble since infection risk is directly correlated with length of insertion. Not to mention, by then, the catheter will have migrated out or become less functional...😛

To be clear, I’m not trying to convince you that your guys’ practice is wrong or risky, I’m more just thinking out loud with what’s going through my head when I read about different peoples’ practices. Great to hear that you guys are utilizing thoracic epidurals though and your surgeons aren’t terrified of them (mostly because they don’t understand them)

 

[AnesRunner]

Dermabond exit site, small Tegaderm, loop catheter, benzoin over Tegaderm all the way up the shoulder, large Tegaderm, Tegaderm strips up to the shoulder. Dermabond and reinforcing rolled edges as they pop up is crucial. Anecdotally, less than 1% of our epidurals "dislodge" or migrate back a little. We often leave them in for 7-8 days for the big Surg Onc cases done here. I will tunnel a peripheral nerve catheter a few times a year (i.e. supraclav cath because there is a burn under the clavicle and can't do an IC cath), and it's a hassle.

We epiduralize most lung transplants. The risk of an epidural space infection for someone not floridly septic is exceedingly low and almost inconsequential.

 

[abolt18]

This definitely the major downside.

I see. I have done this technique, I can’t tell if the epidural stays any better than just securing it normally.

if you do this you no longer see the markings on the catheter when you go tk round on the patient.

 

[deleted87051]

Vidrape spray adhesive was the bomb with incredible long lasting stick. They took it off the market because it smelled wayyyy too good. (And something about sterility too but it was never a real issue.)

 

[deleted162650]

3M 77

 

[Urzuz]

Dermabond exit site, small Tegaderm, loop catheter, benzoin over Tegaderm all the way up the shoulder, large Tegaderm, Tegaderm strips up to the shoulder. Dermabond and reinforcing rolled edges as they pop up is crucial. Anecdotally, less than 1% of our epidurals "dislodge" or migrate back a little. We often leave them in for 7-8 days for the big Surg Onc cases done here. I will tunnel a peripheral nerve catheter a few times a year (i.e. supraclav cath because there is a burn under the clavicle and can't do an IC cath), and it's a hassle.

We epiduralize most lung transplants. The risk of an epidural space infection for someone not floridly septic is exceedingly low and almost inconsequential.

What benefit are you getting by keeping epidurals in for 7-8 days? The marginal benefit that you're getting in the vast majority of patients past 4-5 days is minimal, whereas the risk (though in absolute terms is low) starts to increase exponentially. Add on top of that the fact that transplants (what we were talking about before) are immunocompromised, and your risk goes up even more.

The risks of a lot of complications in anesthesiology are "inconsequential" until they happen to your patient, and then suddenly they become quite consequential. We're in the job of risk mitigation, and unless there is a compelling reason to keep that epidural in past 4-5 days, you're unnecessarily increasing the risk of infection to your patients.

 

[deleted87051]

3M 77

Great for repairing old magnepans. Lacks the Vidrape fragrance.