Successful removal of a knotted fascia iliaca catheter: principles of patient positioning for peripheral nerve catheter extraction.

Peripheral nerve catheters are typically advanced a substantial distance into a perineural sheath, theoretically increasing the risk of catheter knotting and kinking. In this case report, we describe successful removal of a knotted fascia iliaca catheter and discuss principles of nonsurgical catheter extraction. A 64-yr-old woman with bilateral coxarthrosis presented for total hip arthroplasty under combined general/regional anesthesia. A 20-gauge fascia iliaca catheter was inserted before surgery by using a loss-of-resistance "double pop" technique. The catheter was uneventfully advanced 10 cm past the needle tip. After injection of 30 mL of 0.5% bupivacaine with 1:200,000 epinephrine and 100 microg of clonidine, general anesthesia was induced. An infusion of 0.1% bupivacaine at 20 mL/h was initiated in the recovery room for postoperative analgesia. Approximately 48 h later, resistance was encountered during catheter removal. Catheter extraction was attempted by altering patient positioning, including the supine position during which the catheter placement had occurred. Successful catheter removal was achieved by decreasing tension on the fascia lata and fascia iliaca through flexion of the hip joint and by applying firm, steady traction. The catheter was removed intact with a knot approximately 2 cm from the distal tip. We conclude that the principles for removal of entrapped peripheral catheters are not well known and may differ from those for neuraxial catheters. Patient positioning to minimize pressure and tension on the perineural soft tissues may facilitate catheter removal.