Sir,Outward or inward migration of epidural catheters is a common problem encounters during epidural catheter insertion. Different catheter fixation techniques are been described in the medical literature. The technique of making subcutaneous tunnel for securing epidural catheter is safe and free of cost technique.[123] We share an interesting case of knot in epidural catheter while making subcutaneous skin tunnel for epidural catheter fixation. A 22-year-old boy was posted for total open nephrectomy for angiomyolipoma of the left kidney. For intraoperative and postoperative analgesia epidural catheter was inserted at T12-L1 inters pace. An 18 gauge epidural needle was used and procedure was performed using loss of resistance technique. Epidural catheter was fixed by tunneling the catheter at subcutaneous tissue depth. However, just before fixing the catheter with clear transparent adhesive tape a knot appeared on the epidural catheter [Figure 1a]. Now, we had two options one is either to open the epidural drug port and release the catheter and again pass the epidural catheter from subcutaneous tunnel to release the knot. This is followed by again passing the catheter from subcutaneous tunnel. However, such a manoeuvre will breach aseptic practice. Another option we had was to leave the catheter in its natural curve form and fix it in that manner. As the epidural test dose of 3 mL (2% xylocaine with adrenaline 1:200,000) went smooth with no obstruction, so we had planned to fix the epidural catheter in its own natural curve [Figure 1b], and again checked the epidural catheter for any resistance to drug injection [Figure 1c]. In absence of any resistance for drug injection, we went ahead with our epidural analgesia. Epidural analgesia was given by 0.0625% bupivacine with 2 µg/mL of fentanyl with elastomeric pump, and patientpain was controlled predictably. The epidural catheter was removed on 4th day uneventfully.
Figure 1
How to fix the epidural catheter and check for its proper functioning
How to fix the epidural catheter and check for its proper functioningReported incidence of epidural abscess is around 0.01–0.1%.[4] In any circumstances if we breech the aseptic standards there are high chances of contamination of epidural catheter tip. Coming from an unsterile side to sterile side and opening of catheter port just to unknot the catheter might result in contamination. Precaution should be taken while fixing the epidural catheter using subcutaneous tunnel technique, but inadvertent incidences like knot in epidural catheter can happen even in most experienced hands.[5] As in this case test dose given was free flow so we decided to fix the catheter in its own natural curve form and acute pain services where informed. Information to acute pain services and mentioning of such an event in patient medical record is important as it will help in troubleshooting any time if epidural analgesia fails in postoperative period.We want to highlight the fact that this technique can be useful if same incidence of epidural catheter knot occurs during subcutaneous tunneling in clinical practice.
Figure 1