78th Annual PostGraduate Assembly in Anesthesiology (PGA78) 2024

Management of a Retained Epidural Catheter in a Pregnant Patient

Kevin W. Tang1 , Mingzhuo Pei1, Aamod George1,2, Antoine Anderson1,2, Ming Xiong1,2

1. Rutgers New Jersey Medical School 2. Department of Anesthesia and Perioperative Care

BACKGROUND

Epidural Analgesia Overview:

•Commonly used to manage pain during labor and delivery, maintaining patient consciousness.

•Suitable for women requiring prolonged pain relief during labor; also used for long-duration Caesarean sections with combined spinal-epidural methods.

Administration and Patient-Controlled Epidural Analgesia (PCEA):

•Catheter placement in the epidural space enables continuous anesthetic delivery during prolonged labor.

•A study on PCEA with 0.0625% bupivacaine and fentanyl showed 92% satisfaction among 294 women, with fewer than 10% reporting complications.

Complications of Epidural Analgesia:

•Common side effects: hypotension, headache, back pain.

•Rare adverse effects: infection, nerve damage, and exceptionally rare retained catheter fragments.

•Lower concentrations of anesthetics (e.g., 0.0625% bupivacaine) and lipophilic opioids (fentanyl, sufentanil) have decreased adverse events.

Retained Epidural Catheter Fragment – Rare Complication:

•Symptoms range from minor pain to severe complications, though cases are often asymptomatic.

•Incidence is undocumented; case reports guide management, particularly for complex extractions where symptoms or fragment location warrant surgical intervention.

DISCUSSION

Literature Insights on Retained Catheter Management:

•Most cases are asymptomatic and do not require surgery; conservative management often sufficient.

•Cases with persistent pain or neurological symptoms may need neurosurgical intervention to prevent nerve compression or fibrosis.

Imaging and Safety Considerations:

•Immediate imaging (e.g., MRI, CT, or x-ray) advised upon catheter fracture detection; MRI may pose thermal risks with metal-reinforced tips.

•CT imaging used in this case due to metallic spring in catheter tip, prioritizing safety.

Prevention Techniques:

•Suggested techniques to avoid retention include gentle retraction, placing patients in lateral decubitus position, minimizing catheter insertion depth, and using low tension during removal.

Case Insights and Recommendations:

•Fracture likely due to multiple insertion attempts and increased traction.

•Importance of early imaging, understanding catheter type, and patient reassurance emphasized.

•Call for future research on the causes, incidence, and management protocols for retained catheters, as well as MRI compatibility for metal-reinforced tips.

REFERENCES

[1] Hawkins, J.L. (2010) Epidural Analgesia for Labor and Delivery. New England Jour- nal of Medicine, 362, 1503-1510. https://doi.org/10.1056/nejmct0909254

[2] Author (2016) Practice Guidelines for Obstetric Anesthesia: An Updated Report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia and the Society for Obstetric Anesthesia and Perinatology. Anesthesiology, 124, 270-300.

[3] Clivatti, J., Siddiqui, N., Goel, A., Shaw, M., Crisan, I. and Carvalho, J.C.A. (2013) Quality of Labour Neuraxial Analgesia and Maternal Satisfaction at a Tertiary Care Teaching Hospital: A Prospective Observational Study. Canadian Journal of Anes- thesia, 60, 787-795. https://doi.org/10.1007/s12630-013-9976-9

[4] Parnass, S.M. and Schmidt, K.J. (1990) Adverse Effects of Spinal and Epidural Anaes- thesia. Drug Safety, 5, 179-194. https://doi.org/10.2165/00002018-199005030-00003

[5] Sharma, R., Setlur, R., Bhargava, A. and Vardhan, S. (2007) Walking Epidural: An Effective Method of Labour Pain Relief. Medical Journal Armed Forces India, 63, 44-

46. https://doi.org/10.1016/s0377-1237(07)80107-9

[6] Merrer, J., Bonnet, M., Blondel, B., Tafflet, M., Khoshnood, B., Le Ray, C., et al. (2021) Predictors of Incomplete Maternal Satisfaction with Neuraxial Labor Analgesia: A Nationwide Study. Anaesthesia Critical Care & Pain Medicine, 40, Article 100939. https://doi.org/10.1016/j.accpm.2021.100939

78th Annual PostGraduate Assembly in Anesthesiology (PGA78) 2024

Management of a Retained Epidural Catheter in a Pregnant Patient

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