Expect the unexpected – Breach in continuous nerve block catheter

V. Subashini*, Khaja Mohideen, P. Sasi Kumar, K. Senthil Kumar

Department of Anaesthesiology, Kauvery Hospitals, Trichy

Abstract

The placement of continuous peripheral nerve block catheters on an ambulatory basis is increasing in day-to-day practice. There are a few reports of complications associated with peripheral nerve block catheter removal in the literature such as inability to remove peri-neural catheters occurs due to knotting or breakage of the catheter. Most of these cases required surgical intervention for catheter removal. We here describe a case of retained continuous sciatic nerve block catheter in the popliteal region.

Keyword: Continuous nerve block catheter, catheter fracture, knotting and kinking of catheter, Tissue adhesion

Background

There are several reports of successful use of peripheral nerve blockade. Removal of the indwelling catheter is presumed to be easy and painless, and there are only a few reports of complications associated with peripheral nerve block catheter removal, hence making this technique an attractive alternative to prolonged inpatient stay

Case Presentation

A 42-yr-old male with diabetes and coronary artery disease underwent right transfemoral and popliteal embolectomy under combined spinal epidural anaesthesia.

On POD 3 following epidural catheter removal pain persisted despite IV analgesic for which the patient was counselled for the insertion of a continuous sciatic nerve block catheter in the popliteal region and he agreed for the same.

The procedure was performed under sterile precautions using a 18G epidural catheter. The catheter was advanced 3 cm past the needle tip under ultrasound guidance using an out-of-plane approach with continuous nerve stimulation technique. The proximal end of the catheter was secured at the skin surface using 2-0 ethilon in the popliteal region on posterior aspect of thigh.

Post-procedure, patient was on continuous infusion with Baxter pump [ROPIVACAINE 0.15%] and the pain relief was adequate with VAS score of less than 2/10.

After 5 days on POD-8 patient was posted for wound relook.

The nerve block catheter removal was planned and while attempting to remove the skin sutures, there was a breach in the catheter and we could find that nearly 5cm of catheter was found missing. Both the surgeon and patient were informed about the buried fractured catheter tip and it was visualized using ultrasound (Fig. 1). The residual catheter was removed by surgical intervention (Fig. 2) under spinal anaesthesia.

Discussion

Complications related to peripheral nerve block catheter removal are reported rarely in literatures. Previously described cases involved shearing or knotting of catheters.

A case report by D Trans [1], involving an Arrow Stimucath TM Continuous Nerve catheter removal sheath came off, leaving the stimulating wire in place. There are no other reports of a similar catheter separation during attempted catheter removal. There can be various causes for difficulty with catheter removal, such as a technical aspect of catheter placement, catheter design and tissue reaction at the catheter site.

If we encounter any resistance during catheter advancement, it is our practice to remove the entire needle& catheter system as a single unit, otherwise there is a possibility of shearing of catheter and snaring of the same, resulting in retaining of foreign body in tissue.

The cause of catheter separation can be due to improper catheter tunnelling. It is possible that a tissue reaction can occur with the catheter in situ, leading to the formation of adhesions. Too forceful attempt during catheter removal could potentially result in catheter fracture.

Excessive catheter advancement can be a cause of difficult catheter removal due to knotting or kinking of the catheter.

Factors that may contribute to catheter shearing would include both the sharpness and the bevel angle of the insulated needle.

In a Case by Lee [2], complete breakage of the catheter was noted at the time of catheter removal. The shearing or weakening of the catheter most likely occurred during guide wire removal with the needle still in situ.

Much of the concern in long term nerve block catheters usage revolves around infection, local anaesthetic toxicity, and injury due to an insensate extremity3. However, our case suggests that careful catheter removal should be equally concerning. Too forceful attempt at catheter removal could potentially result in nerve injury (avulsion from a knotted catheter), bleeding or catheter fracture.

Conclusion

Further research is needed to explore the safety of indwelling catheter removal in the ambulatory setting and to determine whether a different catheter design may reduce or avoid catheter disruption during removal.

Reference:

Tran D, et al. Retained and cut stimulating infraclavicular catheter. Can J Anesth, 2005;52(9):998-9.
Lee BH, et al. Shearing of a peripheral nerve catheter. Anesth Analg 2002;95:760-1.
Clendenen SR, et al. Complications of peripheral nerve catheter removal at home: case series of five ambulatory inter-scalene blocks. Can J Anesth. 2011;58(1):62-67.

Dr. S. Khaja Mohideen

Anaesthesiologist

Dr. P. Sasi Kumar

Anaesthesiologist

Dr. K. Senthil Kumar

Head of the Department – Anaesthesiology and Toxicology

Expect the unexpected – Breach in continuous nerve block catheter