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Background: The migration of pediatric thoracic epidural catheters via a thoracic insertion site has been described. We assessed the migration of caudally threaded thoracic epidural catheters in neonates and infants at our institution., Methods: The anesthesia records and diagnostic imaging studies of neonates and infants who had caudal epidural catheters placed during a 26-month period at our hospital were analyzed. Imaging studies were reviewed for changes in epidural catheter tip position., Results: Eighty-five patients 1-325 days of age (median, 51 days; interquartile range, 39-78 days) and weights of 2.5-9.5 kg (median, 5 kg; interquartile range, 4.3-5.8 kg) met the study criteria. Fifty-four (64%) of the patients (95% CI, 52%-73%) experienced catheter migration of 1 or more vertebral levels (range, 3 levels caudad [outward] to 3 levels cephalad [inward]), and 23 (27%) of the patients (95% CI, 18%-38%) experienced catheter migration to the T4 level or higher. Migration of 2 or more vertebral levels occurred only in children who weighed <6 kg and were under 73 days of age., Conclusions: Epidural catheter migration occurs commonly in neonates and infants. Postoperative imaging is crucial to confirm catheter tip location after epidural catheter placement, as failure to assess catheter migration might result in suboptimal analgesia or other undesirable outcomes.

Background: Insufficient fixation of an epidural catheter may result in migration of the catheter and eventual catheter failure. However, the best fixation method remains to be established. Aron Alpha A (2-ethyl cyanoacrylate) adhesive is approved for clinical use and can be used for surgical adhesion to both skin and blood vessels. We hypothesized that the addition of Aron Alpha A adhesive to film dressing would result in consistent and dependable catheter fixation., Methods: In this study, 58 women who were scheduled for cesarean delivery under spinal and epidural anesthesia were recruited. Patients were randomly assigned to a control or treatment group. In the control group, the catheter was fixed solely by film dressing. In the treatment group, a small amount of Aron Alpha A was applied at 2 sites along the catheter. The fixation area was then covered by film dressing. The catheter insertion length was recorded after fixation (T0), immediately postoperatively (T1), on postoperative day 1 (T2), and when the catheter was removed (T3). The change in insertion length from T0 to T3 between the 2 groups was the primary outcome measure. The incidence of catheter failure was also recorded. For all comparisons, P < .05 was considered statistically significant., Results: Initially, 58 women were enrolled; however, 3 patients were excluded. From the remaining 55 patients, 27 and 28 were assigned to the control and treatment groups, respectively, and were evaluated. The change in insertion length from T0 to T3 was significantly more in the control group compared with the treatment group (-1.9 ± 2.2 vs 0 ± 0 cm, respectively; P < .001). In the control group, 11 catheters (41%) failed; in the treatment group, all catheters provided effective analgesia throughout the study (P < .001)., Conclusions: Epidural catheter fixation using film dressing combined with 2-ethyl cyanoacrylate adhesive application at 2 sites along the catheter resulted in secure fixation in patients receiving postoperative epidural analgesia for cesarean delivery.

Introduction: The adoption of regional and epidural analgesia in UK military personnel injured in action during Op HERRICK increased from 2008, in line with structural and environmental developments in the UK medical treatment facility. Historically, there have been concerns that invasive analgesic techniques could carry an increased risk of infection, due to the mechanism of injury and the environmental conditions in which the injuries were sustained. Consequently, the epidural and continuous peripheral nerve blockade (CPNB) catheters that were inserted in UK military personnel during a 33-month period of Op HERRICK were clinically and microbiologically examined, after subsequent admission to the University Hospitals Birmingham (UHB) NHS Trust., Methods: Data on epidural and CPNB insertions were collected via the specialist pain service at UHB over the study period, including de novo and replacement insertions performed in both Afghanistan and the UK. Patients were regularly reviewed and relevant clinical concerns were documented in patients' case notes as necessary. The anatomical site, duration of placement and the results of microbiological culture of the epidural and CPNB catheter tips were all recorded., Results: Overall, 236 catheters were assessed, of which 151 catheter tips (64%) were cultured (85 epidural, 66 CPNB). Of these, 48 grew bacteria (34% of cultured epidurals and 29% of cultured CPNB). There was no difference between the colonisation rates of epidurals inserted in Afghanistan and the UK. Only one infection related to a misplaced epidural catheter was confirmed., Conclusions: With the exception of the epidural (34%) and proximal sciatic (42%) catheters, these figures, in a military cohort characterised by significant injury scores, are consistent with those reported for civilian surgical patients. The results strongly support the expansion of regional analgesia during Op HERRICK from 2008 onwards. The outcomes suggest a possible translation into civilian major trauma practice., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Background: Epidural steroids are more effective if administered in the anterolateral epidural space. It follows that the ability to administer local anesthetics in the ipsilateral anterolateral epidural space should likewise improve their efficacy for postoperative epidural analgesia., Questions/purposes: We determined whether epidural catheters can be reliably placed in the ipsilateral anterolateral epidural space using the paramedian approach. Motor responses elicited by electrical stimulation were used to identify lateralization. We further assessed what angle of needle insertion resulted in successful catheter placement., Methods: Epidural anesthesia was performed in 68 patients undergoing total joint arthroplasty using the paramedian approach. FDA-approved electrical stimulating catheters were utilized, and the muscle response elicited was recorded with each centimeter of advancement of the catheter. Digital photographs were taken to determine the angle of needle entry., Results: Using the paramedian approach, an ipsilateral twitch was noted in 66 of the 68 patients (two had no response). With advancement of the catheter (2-5 cm), the twitch remained ipsilateral in 56 but disappeared in 12. The mean angle of the epidural needle was 40° to the midline. All patients had successful epidural anesthesia as evidenced by no response to surgical incision., Conclusions: Epidural catheters can be reliably placed onto the side of surgery using the paramedian approach. This provides the opportunity to more selectively administer epidural local anesthetics., Level of Evidence: Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Objectives: Trigeminal neuralgia (TN) is a rare form of neuropathic facial pain characterised by severe paroxysmal pain in the face. The treatment for trigeminal neuropathic pain disorder continues to be a major therapeutic challenge, as relief provided by medical therapy generally decreases over time. When medical therapy fails either due to poor or diminishing responses to drugs or to unacceptable side effects, peripheral intervention or surgical management of TN should be considered., Study Design: Fourteen patients (eight men and six women) who were not responsive to further medical treatment and who were diagnosed with TN previously at other health centres were selected for treatment. For this purpose, the affected nerve was infused with 60 mL (1 mL h(-1)) of 0.5% bupivacaine HCl with a pain pump via an temporary epidural catheter. Patient's visual analogue scores (VAS) were recorded on the fifth preoperative day and on postoperative day 5, 2 weeks, 1, 3, 6 and 9 months., Results: There was a significant difference between mean preoperative and postoperative VAS value at day 5, 2 weeks, 1, 3, 6 and at the end of 9 months ((68.85 ± 1.43) (13.57 ± 6.68) (11.43 ± 6.70) (14.29 ± 6.52) (20.71 ± 6.41) (20.71 ± 6.41) and (21.43 ± 6.10) respectively; ∗P<0.05). Two of 14 patients did not show any pain relief., Conclusions: Continuous administration of 60 mL of 0.5% bupivacaine HCl at 1 mL h(-1) with a pain pump and epidural catheter can be used as a transition treatment for patients with side effects from high-dose antiepileptic drugs and for patients awaiting neurosurgery or individuals who refuse cranial surgery. It should not be considered as an alternative treatment of neurosurgical approaches, such as MVD, which has a definite long-lasting results., (Copyright © 2011 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: Postoperative pain control via thoracic epidural catheters (TECs) is an important aspect of postoperative care, and ample evidence highlights its positive physiologic effects and superiority to intravenous analgesia. If epidural catheters for postoperative pain relief are used in scoliosis surgery, current practice is the intraoperative placement of the TEC by the surgeon because preoperative placement is considered challenging and dangerous. On the basis of magnetic resonance imaging of scoliotic spines, the authors developed a technique for preoperative placement of TEC and investigated its safety and feasibility., Methods: Patients undergoing anterior scoliosis surgery were included, who received preoperative placement of TEC. Postoperative pain, problems associated with the TEC placement, possible side effects, radiographic data, and insertion levels of the TEC were noted., Results: The apex vertebra was identified as a possible site for TEC placement due to dural sac shift leaving a wider epidural space on the convex side. Scoliosis-induced rotation of the vertebrae required realignment of the needle toward the convex side. Sixty patients were included. The success rate for TEC placement was 96.6%: one failed attempt, one catheter placed intrapleurally, and one patient with Horner syndrome. Seven percent of patients required additional rescue analgesia. All other patients had pain scores within acceptable limits (Visual Analogue Scale <5)., Conclusions: The authors have demonstrated that it is possible to insert a TEC in patients with scoliotic spines with a high degree of success using a redesigned approach and thus provide adequate postoperative analgesia with a single epidural catheter. However, precautions have to be taken.

We describe a documented migration of a thoracic epidural catheter into the thoracic cage in a 5-wk-old with DiGeorge's syndrome and an uncorrected acyanotic Tetralogy of Fallot who underwent laparotomy for malrotation, gastric fundoplication, and gastrostomy tube insertion under combined general and epidural anesthesia. A 20-gauge stimulating catheter was inserted caudally and advanced cephalad to the thoracic level while applying a low electrical current (1-10 mA) to confirm epidural placement at approximately T5-6. Despite good pain control through the third postoperative day, using an epidural infusion of bupivacaine 0.1% at 1-1.2 mL/h, radiography demonstrated catheter migration into the seventh intercostal space.

During the past 3 years, the US Food and Drug Administration (FDA) has received a growing number of adverse event reports on the breakage or fracturing and retention of anesthetic conduction device tips with associated complications. Serious injuries and other problems such as spinal stenosis, nerve root compression, and subcutaneous effusion can result. Several case reports demonstrate how the problems occur; some illustrate the severity of the problem. All cases are from adverse event reports in the FDA Center for Devices and Radiological Health (CDRH) Manufacturer and User Facility Device Experience database. Frequently, in the interest of not causing patient harm, a device fragment might not be removed as long as the patient is not neurologically compromised or at risk for infection or there is little potential for migration of the fragmented piece. On many occasions, the fragments remain in patients without their knowledge. The FDA wants to raise awareness of the problem and its potential impact in creating complications, encourage the practice of informing patients of the fragmented device, and promote reporting of such incidents to CDRH via the MedWatch reporting system. Based on a search of the current literature, recommendations for prevention are suggested.

We often experience migration of an epidural catheter into an undesirable space. Migration of an epidural catheter into the subarachnoid space is a potentially lethal complication. Although almost all migrations of epidural catheters have been reported to occur at insertion of the catheter, we experienced a case of catheter migration into the subarachnoid space two days after its insertion. The symptoms caused by this migration were motor paralysis in the lower extremities and sensory disturbance of the trunk. Neurological and hemodynamic changes in a patient who is undergoing continuous epidural infusion of local anesthetics should be monitored carefully.

New catheter materials, termed Hydrogels, have been developed recently that are stiff until exposed to hydration. The purpose of this study was to compare the 30 and 180 day histopathology of catheters composed of a common silicone elastomer versus a Hydrogel elastomer blend (HEB). Epidural catheters composed of either silicone or HEB were implanted in 19 yearling ewes for either 30 or 180 days. The degree of fibrotic reaction in the epidural space, muscle and subcutaneous tissue was assessed using both histopathology and quantitative imaging analysis. A separate subset of three ewes were implanted with HEB epidural catheters connected to subcutaneously implanted ports through which twice weekly injections of saline were given. There was no evidence of significant neurotoxicology associated with either the silicone or the HEB catheter materials. However, the silicone elastomer group had a quantifiably greater degree of fibrosis than the HEB group of both implant durations. The mean cross sectional area (sq. mm) of epidural pericatheter fibrosis was significantly smaller in the HEB group compared with the silicone group (0.491 in the HEB group and 1.585 in the silicone group at 30 days [P = 0.02] and 0.28 and 1.401 at 180 days [P = 0.0001]. The HEB catheter was easily inserted with standard epidural needles facilitated by the inherent stiffness of the catheter prior to hydration. HEB catheters remained patent throughout 30 days of saline injections per implanted ports. Silicone catheters demonstrated increased fibrosis relative to the HEB catheter material in the epidural space and in subcutaneous tissue.

26 days past an obstetric catheter epidural anesthesia a subdural haematoma right fronto-temporal was diagnosed and relieved by operation in a primipara of 19 years of age. Already several days after the delivery the patient was suffering recurrent headaches, at first misinterpreted as post-spinal headaches. Weeks later a cranial computer tomography lead to the right diagnosis. Although the occurrence of a subdural haematoma after catheter epidural anesthesia is extremely rare, untypical headaches following spinal, epidural or caudal procedures, should call your attention towards this complication. Because of the pressing mechanisms during childbearing, delivering mothers run the risk of a subdural haematoma.

We investigated the roentgenogram of the epidural catheter in 82 patients in whom the injection of local anesthetics had no effect. Contrast medium 0.5 ml was injected through the epidural catheter and antero-posterior roentgenogram was taken. The roentgenograms were categorized into three patterns, according to the relationship of the catheter to the pedicle of lamina, or to the spread of contrast medium. In 43 cases, the catheter passed through the intervertebral foramen. The tip of the catheter was located outside the foramen, and the contrast medium spread outside the vertebra. In 4 cases, the tip of the catheter was located laterally in the vertebral column, and only the catheter itself was contrasted but no spread of medium was observed. The catheter was thought to be misinserted intravascularly. In other 35 cases, catheter ran laterally on the pedicle of lamina, or the spread of medium 2 mins after the injection was indicated by a dumpling-shape even when the tip was in the vertebral column. In these cases, the catheter was thought not to be outside the epidural space.

Unlabelled: The aim of this study was to determine at which lumbar spinal level the tips of different epidural catheters may be located following insertion through cranially directed Tuohy needles. Previous studies varied with respect to materials and methods and may have left the false impression that different types of catheters are necessary or actually more advantageous for particular needs., Materials and Methods: One hundred seventy-five trauma patients scheduled for surgery on their lower extremities received continuous epidural anesthesia. With the patient in a sitting position, a midline lumbar puncture was made and one of six different plastic catheters advanced 5 cm beyond the tip of the Tuohy needle. Postoperatively the catheters were filled with Iopamidol and ap X-rays taken of the lumbar spine. The catheter tips were declared to be "cranial" if they were more than 2 cm above, "caudal" if they were more than 2 cm below, and "equal to" if they were within 2 cm of the puncture site., Results: Of the 175 documented catheter tips 47.7% assumed a cranial position, 9.2% were in a caudal position, and 43.4% remained within the level of insertion. A statistical analysis comparing catheter tip location among the six epidural catheter models tested did not reveal any significant differences., Discussion: In a clinically controlled study based on the Tuohy principle of inserting catheters through a needle with a Huber point, different epidural catheter models were inserted into the lumbar epidural space and their locating radiologically documented. It was shown that 52% of the epidural catheters that had been advanced 5 cm into the lumbar epidural space through a cephaled-directed Tuohy needle did not reach the intended spinal level cranial to the puncture site. The results are similar to those of earlier studies, which were not systematic and involved a variety of methods and materials. One reason for the unreliable ascension of the catheter tips may be the many structures within the epidural space which may dislodge and divert the catheters during advancement. In addition, it has sometimes been observed that a change in the patient's position may cause a spinous process cranial to the puncture site to exert pressure and traction on the catheter, partially dislodging it. It must thus be concluded that the use of a Tuohy needle cannot guarantee cranial ascension of an epidural catheter in the lumbar epidural region.

Two cases of secondary subarachnoidal dislocation of lumbar epidural catheters are reported. The first catheter was placed, tested, and injected with 20 ml local anesthetic in order to achieve intraoperative anesthesia up to the T4 level. On the 2nd postoperative day the test dose produced paralysis of the lower extremities; liquor now could be aspirated. The second catheter had been introduced into the epidural space immediately after injection of 15 ml local anesthetic through the needle. Use of this catheter for postoperative analgesia led to total spinal anesthesia in spite of negative aspiration and test dose prior to injection of 7 ml local anesthetic. Implications of these two cases concerning placement procedures and monitoring during reuse of catheters placed some time before are discussed.

The purpose of this study was to compare two epidural catheters--the Portex epidural catheter and Vas-Cath catheter. One hundred and fifty patients in labour who received epidural anaesthesia were selected and either one or the other catheter was used, based on random assignment. Ease of insertion, maintenance and removal of the catheter were assessed, as was the incidence of blood return and paraesthesiae during epidural catheter insertion. There were no significant differences between the catheters as far as insertion, maintenance and removal were concerned. However, the incidence of paresthesiae was 44 per cent with the Portex and 24 per cent with Vas-Cath catheters (p less than 0.008). The incidence of blood vessel trauma was 12 per cent with the Portex and 6.7 per cent with the Vas-Cath catheter (p = NS). Choice of epidural catheter is a factor to be considered in minimizing the incidence of blood vessel trauma or paresthesiae.

Migration of thoracic epidural catheters was evaluated in 25 patients by three methods either after placement of the catheter or immediately after surgery. The first method was the determination of the depth of the catheter from the skin, the second the determination of the level of sensory blockade which resulted from a test dose of a local anesthetic agent, while the third consisted of radiological visualisation of the catheter tip in the epidural space with radiopaque dye. The evaluations were repeated on the third or fourth day after operation. We observed an inward movement of the catheter in 56% of the patients instead of the expected outward movement. This inward movement was accompanied by a higher level of sensory blockade. No relationship with radiological visualisation was found.

The authors conducted a two-part study to evaluate the efficacy of 1 ml of air as a "test dose" for detection of intravenously located epidural catheters. In part 1, a Doppler fetal heart rate monitoring probe was placed over the precordium of 33 laboring patients in whom functioning epidural catheters were in place. Each patient received, more than 90 s apart, in random order: 10 ml of agitated saline (containing less than 0.5 ml of air microbubbles) via a peripheral vein; 2 ml of air via the epidural catheter; and a sham injection (i.e., nothing injected). In all 33 cases, a blinded observer identified Doppler changes 10-30 s following the injection of air (microbubbles) via peripheral vein. Doppler changes were never heard following epidural air injection (P less than 0.001 compared with iv air microbubble injection) or the sham injection (P less than 0.001 compared with iv air microbubble injection). In part 2, the authors listened for Doppler heart tone changes while injecting 1 ml of air via catheters that were accidentally inserted in the epidural veins of five other patients. Unequivocal Doppler changes compatible with intracardiac air always occurred within 3 s, and no signs or symptoms of air embolism developed. The results suggest that 1 ml of air may be a suitable indicator of iv epidural catheter location.

In general surgical wards postoperative epidural analgesia was performed in 286 patients consecutively. Epidural catheters were kept in place 8.3 days in the average with a minimum of 24 h and a maximum of 45 d. Bupivacain was applied as a 0.25% solution with an average daily dose of 75-250 mg and single doses of 12.5-50.0 mg. An uncomplicated course was noticed in 250 cases, 19 cases showed haemodynamic, 7 cases neurologic and 10 cases technical complications. Severe decrease of systolic blood pressure more than 30% of the control value was due to postoperative haemorrhage, to anaemia with Hgb-concentration lower than 11 g/dl or to untreated chronical hypertension. On the basis of these observations a list of conditions has been drawn up which should be adhered to when epidural catheters are used for postoperative pain relief in normal wards.