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Deng NH, Chen XC, Quan SB. Unique method for removal of knotted lumbar epidural catheter: A case report. World J Clin Cases 2024; 12:1824-1829. [PMID: 38660084 PMCID: PMC11036471 DOI: 10.12998/wjcc.v12.i10.1824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 02/03/2024] [Accepted: 03/04/2024] [Indexed: 04/02/2024] Open
Abstract
BACKGROUND Combined spinal-epidural (CSE) anesthesia is the preferred anesthesia method for cesarean delivery. The use of an epidural catheter is essential for administering additional drugs intraoperatively and managing postoperative pain. However, the insertion of epidural catheters is associated with various complications, such as total spinal anesthesia, symptoms indicative of spinal nerve root irritation, and challenges in epidural catheter removal. CASE SUMMARY We present a case report of a challenging epidural catheter removal due to knotting. The lumbar computed tomography scan results revealed that the catheter formed a tight knot in the epidural space. We used a novel extubation method and successfully removed the catheter. CONCLUSION The operator can use opposite forces to "spiral" apart the spinal joints by positioning the patient's body in a specific position. The findings indicate that, when combined with imaging examination results, this method is effective for the removal of epidural catheters.
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Affiliation(s)
- Nian-Hua Deng
- Anesthesia and Surgery Center, Dongguan Songshan Lake Central Hospital, Dongguan 523326, Guangdong Province, China
| | - Xiao-Cong Chen
- Anesthesia and Surgery Center, Dongguan Songshan Lake Central Hospital, Dongguan 523326, Guangdong Province, China
| | - Shou-Bo Quan
- Anesthesia and Surgery Center, Dongguan Songshan Lake Central Hospital, Dongguan 523326, Guangdong Province, China
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Pinho JM, Coelho DA. Confirming identification of the epidural space: a systematic review of electric stimulation, pressure waveform analysis, and ultrasound and a meta-analysis of diagnostic accuracy in acute pain. J Clin Monit Comput 2023; 37:1593-1605. [PMID: 37481480 DOI: 10.1007/s10877-023-01056-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 06/28/2023] [Indexed: 07/24/2023]
Abstract
To review the use of epidural electric stimulation test, pressure waveform analysis, and ultrasound assessment of injection as bedside methods for confirming identification of the epidural space in adults with acute pain, the PubMed database was searched for relevant reports between May and August 2022. Studies reporting diagnostic accuracy with conventional Touhy needles and epidural catheters were further selected for meta-analysis. Sensitivity and specificity were estimated using univariate logistic regression for electric stimulation and pressure analysis, and pooling of similar studies for ultrasound. Risk of bias and applicability was assessed using QUADAS-2. For electric stimulation, pressure waveform analysis, and ultrasound, respectively 35, 22, and 28 reports were included in the review and 9, 9, and 7 studies in the meta-analysis. Electric stimulation requires wire-reinforced catheters and an adequate nerve stimulator, does not reliably identify intravascular placement, and is affected by local anaesthetics. Sensitivity was 95% (95% CI 93-96%, N = 550) and specificity unknown (95% CI 33-94%, N = 44). Pressure waveform analysis is unaffected by local anaesthetics, but does not identify intravascular nor intrathecal catheters. Sensitivity was 90% (95% CI 72-97%, N = 694) and specificity 88% (95% CI 78-94%, N = 67). B-mode, M-mode and doppler ultrasound may be challenging, and data is still limited. Risk of bias was significant and accuracy estimates must be interpreted with caution. Electric stimulation and pressure waveform analysis seem clinically useful, although they must be interpreted cautiously. In the future, clinical trials in patients with difficult anatomy will likely be most useful. Ultrasound requires further investigation.
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Affiliation(s)
- João Mateus Pinho
- Department of Anaesthesiology, Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisbon, Portugal.
- Serviço de Anestesiologia, Instituto Português de Oncologia de Lisboa, Rua Prof. Lima Basto, 1099-023, Lisboa, Portugal.
| | - David Alexandre Coelho
- Department of Anaesthesiology, Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisbon, Portugal
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van den Bosch OFC, Gleicher Y, Arzola C, Siddiqui N, Downey K, Carvalho JCA. Color flow Doppler in spinal ultrasound: a novel technique for assessment of catheter position in labor epidurals. Reg Anesth Pain Med 2022; 47:775-779. [PMID: 36215115 DOI: 10.1136/rapm-2022-103948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 08/26/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Ultrasound is commonly used to facilitate epidural catheter placement. However, data are lacking regarding its potential to confirm its position in the epidural space. Our aim was to visualize flow in the epidural space of patients receiving epidural analgesia for labor using color flow Doppler ultrasound. METHODS We conducted a prospective observational cohort study that included patients who had delivered vaginally under epidural analgesia. We used a 5-2 mHz curvilinear probe in a left and right paramedian longitudinal oblique view to visualize the anterior and posterior complex at the interspace of epidural catheter insertion, one and two interspaces above and below. At each window, the color flow Doppler function was used to visualize flow within the epidural space on injection of normal saline (1 mL). If no flow was visualized at any interspace, one assessment at the level of insertion was repeated with a 1 mL air/saline mixture. We studied a convenience sample size of 40 patients. RESULTS We visualized flow in the epidural space in all 40 patients. Flow was visualized on injection of 1 mL of saline in 37/40 patients (93%). In the remaining 3/40 patients (7%), flow was visualized with an air/saline mixture. Flow on injection of saline was visualized only at the interspace of insertion in 26/37 patients (70%), at the interspace of insertion and one interspace above in 10/37 (27%), or only at one interspace above in 1/37 (3%). Flow was visualized only on the left or on the right paramedian view in 19/37 patients (51%), despite a symmetrical sensory block in all patients. CONCLUSION Color flow Doppler ultrasound is a feasible and fast way to determine flow in the epidural space in the obstetric population. Its potential clinical uses are confirmation of the epidural catheter position after placement, as well as troubleshooting of unsatisfactory epidural analgesia. Interestingly, our results suggest that epidural catheters predominantly remain at the interspace of insertion. TRIAL REGISTRATION NUMBER NCT05126745.
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Affiliation(s)
- Oscar F C van den Bosch
- Department of Anesthesiology and Pain Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Yehoshua Gleicher
- Department of Anesthesiology and Pain Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Cristian Arzola
- Department of Anesthesiology and Pain Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Naveed Siddiqui
- Department of Anesthesiology and Pain Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Kristi Downey
- Department of Anesthesiology and Pain Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Jose C A Carvalho
- Department of Anesthesiology and Pain Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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Maeda N, Maeda M, Tanaka Y. Direct Visualization of Cervical Interlaminar Epidural Injections Using Sonography. Tomography 2022; 8:1869-1880. [PMID: 35894022 PMCID: PMC9341393 DOI: 10.3390/tomography8040157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 07/18/2022] [Accepted: 07/20/2022] [Indexed: 11/24/2022] Open
Abstract
In this case series, we describe a novel ultrasound (US)-guided cervical interlaminar epidural steroid injections (CILESIs) procedure that does not depend on the loss-of-resistance method for epidural space identification. A needle is introduced into three US-identified structures (triple bar sign), the interspinal ligament, ligamentum flavum, and dura mater. The injectants are monitored using superb microvascular imaging during injection. Here, we demonstrate the use of US-guided CILESIs in nine cases and propose the use of sonography, rather than conventional methods, for easier and safer cervical epidural injections. Sonography for direct visualization of cervical epidural injection may allow for outpatient injections.
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Affiliation(s)
- Nana Maeda
- Maeda Orthopaedic Clinic, 864-1 Kidera-cho, Nara 630-8306, Japan;
| | - Manabu Maeda
- Maeda Orthopaedic Clinic, 864-1 Kidera-cho, Nara 630-8306, Japan;
- Correspondence:
| | - Yasuhito Tanaka
- Department of Orthopedics, Nara Medical University, 840 Shijo-cho Kashihara, Nara 634-8521, Japan;
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Cavaliere F, Allegri M, Apan A, Calderini E, Carassiti M, Cohen E, Coluzzi F, Di Marco P, Langeron O, Rossi M, Spieth P, Turnbull D. A year in review in Minerva Anestesiologica 2019. Anesthesia, analgesia, and perioperative medicine. Minerva Anestesiol 2021; 86:225-239. [PMID: 32118384 DOI: 10.23736/s0375-9393.20.14424-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Franco Cavaliere
- Department of Cardiovascular and Thoracic Sciences, A. Gemelli University Polyclinic, IRCCS and Foundation, Sacred Heart Catholic University, Rome, Italy -
| | - Massimo Allegri
- Unità Operativa Terapia del Dolore della Colonna e dello Sportivo, Policlinic of Monza, Monza, Italy.,Italian Pain Group, Milan, Italy
| | - Alparslan Apan
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, University of Giresun, Giresun, Turkey
| | - Edoardo Calderini
- Unit of Women-Child Anesthesia and Intensive Care, Maggiore Polyclinic Hospital, Ca' Granda IRCCS and Foundation, Milan, Italy
| | - Massimiliano Carassiti
- Unit of Anesthesia, Intensive Care and Pain Management, Campus Bio-Medico University Hospital, Rome, Italy
| | - Edmond Cohen
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Thoracic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Flaminia Coluzzi
- Unit of Anesthesia, Department of Medical and Surgical Sciences and Biotechnologies, Intensive Care and Pain Medicine, Sapienza University, Rome, Italy
| | - Pierangelo Di Marco
- Department of Cardiovascular, Respiratory, Nephrological, Anesthesiologic, and Geriatric Sciences, Sapienza University, Rome, Italy
| | - Olivier Langeron
- Department of Anesthesia and Intensive Care, Henri Mondor University Hospital, Sorbonne University, Assistance Publique-Hôpitaux de Paris, Créteil, France
| | - Marco Rossi
- Institute of Anesthesia and Intensive Care, Sacred Heart Catholic University, Rome, Italy
| | - Peter Spieth
- Department of Anesthesiology and Critical Care Medicine, University Hospital of Dresden, Dresden, Germany
| | - David Turnbull
- Department of Anaesthetics and Neuro Critical Care, Royal Hallamshire Hospital, Sheffield, UK
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