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Separation of stimulating catheters for continuous peripheral regional anesthesia during their removal - two case reports and a critical appraisal of the use of steel-coil containing stimulating catheters.

Wiesmann T, Wallot P, Nentwig L, Beermann AV, Wulf H, Zoremba M, Al-Dahna T, Eschbach D, Steinfeldt T - Local Reg Anesth (2015)

Bottom Line: Stimulating catheters are widely used for continuous peripheral nerve block techniques in regional anesthesia.The incidence of reported complications is somewhat similar to that for non-stimulating catheters.Anesthesiologists should strictly avoid catheter shearing during insertion, adhere to the manufacturer's instructions, and take care during catheter removal.

View Article: PubMed Central - PubMed

Affiliation: Department of Anesthesia and Intensive Care Medicine, University Hospital Marburg, Marburg, Germany.

ABSTRACT

Purpose: Stimulating catheters are widely used for continuous peripheral nerve block techniques in regional anesthesia. The incidence of reported complications is somewhat similar to that for non-stimulating catheters. However, as many stimulating catheters contain a coiled steel wire for optimal stimulation, they may cause specific complications.

Clinical features: In this report, we present two cases of complicated removals of stimulating catheters. During both removals, a part of the metal wire was left "decoiled" next to the supraclavicular and interscalene plexus, respectively. The strategies used to determine steel wire localization and a description of the successful removal of these steel wires are included in this report.

Conclusion: Catheter separation and problems with residual metal wire components of stimulating catheters seem to be a rare but specific problem during removal. Anesthesiologists should strictly avoid catheter shearing during insertion, adhere to the manufacturer's instructions, and take care during catheter removal. Manufacturers should focus on technical solutions to avoid rare but relevant complications such as catheter tip decoiling and separation of stimulating catheters during removal.

No MeSH data available.


Related in: MedlinePlus

Indwelling steel wire and separated polyurethane catheter at the supraclavicular plexus.
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f1-lra-8-015: Indwelling steel wire and separated polyurethane catheter at the supraclavicular plexus.

Mentions: A 75-year-old woman (ASA II, body mass index 29) was scheduled for arthroscopic shoulder surgery due to subacromial impingement. She gave written consent to participate in a randomized controlled trial comparing the clinical effectiveness of supraclavicular and interscalene nerve block catheters for arthroscopic shoulder surgeries. Before the induction of general anesthesia, a supraclavicular nerve block catheter (stimulating continuous peripheral nerve block catheter, Arrow StimuCath, 18 G Tuohy needle, 20 G catheter, Teleflex Medical Germany, Kernen, Germany) was positioned under mild sedation according to the randomization result. Under aseptic conditions,5 in this case, a lateromedial approach was chosen under ultrasound guidance (in-plane approach) after visualization of the subclavian artery and the supraclavicular plexus.6 Percutaneous advancement of the 18 G Tuohy needle resulted in a good needle tip position next to the plexus and a good stimulation result (0.8 mA/0.1 ms) with a typical biceps response. After removal of the needle stylet, the stimulating catheter (20 G) was inserted into the needle, connected with the nerve stimulator and carefully advanced to approximately 4.5 cm over the needle tip. No further needle repositioning or withdrawal of the catheter was performed. Finally, after successful stimulation results via the catheter, the indwelling catheter stylet was removed, followed by complete needle withdrawal. As the patient was participating in a clinical study unrelated to the issue of this case report, correct positioning of the catheter was documented, including a total time of 5 minutes between skin puncture and the beginning of sterile draping of the inserted catheter by our study assistant. The postoperative course was without any relevant complications under a continuous flow of ropivacaine 0.2% (start flow 4 mL/h, at first postoperative day 1 reduction to 2.5 mL/h). Initial numbness after a start bolus of 10 mL ropivacaine 0.2% was resolved on the first postoperative day. Catheter removal was scheduled for the second postoperative day. After removal of the sterile draping, the responsible pain nurse withdrew the catheter using gentle traction but stopped immediately when she noticed catheter separation (see Figure 1). Accordingly, she informed the responsible consultant, who unfortunately could not remove the indwelling residual steel wire. Notably, the patient complained of pain during gentle traction via the residual wire. Another removal attempt was performed in our post anesthesia care unit under standard monitoring and mild analgosedation using fentanyl 0.1 mg intravenously. Under ultrasound guidance, the residual wire was traced backwards to its final position next to the supraclavicular plexus. Traction of the wire resulted in tissue movements next to the plexus fascia and patient discomfort. The completely removed polyurethane component was visually checked and showed no signs of incisions, kinking or otherwise expected damage. Under sterile conditions, the proximal polyurethane catheter component was cut away. In another attempt, the residual wire was threaded through a 16 G intravenous catheter (Braunuele, B Braun Medical, Melsungen, Germany) and then the catheter was advanced retrogradely through the skin until resistance occurred (~4 cm beneath the skin). Another attempt to remove the indwelling wire through this artificial tunnel under forced traction unfortunately failed again.


Separation of stimulating catheters for continuous peripheral regional anesthesia during their removal - two case reports and a critical appraisal of the use of steel-coil containing stimulating catheters.

Wiesmann T, Wallot P, Nentwig L, Beermann AV, Wulf H, Zoremba M, Al-Dahna T, Eschbach D, Steinfeldt T - Local Reg Anesth (2015)

Indwelling steel wire and separated polyurethane catheter at the supraclavicular plexus.
© Copyright Policy
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4492648&req=5

f1-lra-8-015: Indwelling steel wire and separated polyurethane catheter at the supraclavicular plexus.
Mentions: A 75-year-old woman (ASA II, body mass index 29) was scheduled for arthroscopic shoulder surgery due to subacromial impingement. She gave written consent to participate in a randomized controlled trial comparing the clinical effectiveness of supraclavicular and interscalene nerve block catheters for arthroscopic shoulder surgeries. Before the induction of general anesthesia, a supraclavicular nerve block catheter (stimulating continuous peripheral nerve block catheter, Arrow StimuCath, 18 G Tuohy needle, 20 G catheter, Teleflex Medical Germany, Kernen, Germany) was positioned under mild sedation according to the randomization result. Under aseptic conditions,5 in this case, a lateromedial approach was chosen under ultrasound guidance (in-plane approach) after visualization of the subclavian artery and the supraclavicular plexus.6 Percutaneous advancement of the 18 G Tuohy needle resulted in a good needle tip position next to the plexus and a good stimulation result (0.8 mA/0.1 ms) with a typical biceps response. After removal of the needle stylet, the stimulating catheter (20 G) was inserted into the needle, connected with the nerve stimulator and carefully advanced to approximately 4.5 cm over the needle tip. No further needle repositioning or withdrawal of the catheter was performed. Finally, after successful stimulation results via the catheter, the indwelling catheter stylet was removed, followed by complete needle withdrawal. As the patient was participating in a clinical study unrelated to the issue of this case report, correct positioning of the catheter was documented, including a total time of 5 minutes between skin puncture and the beginning of sterile draping of the inserted catheter by our study assistant. The postoperative course was without any relevant complications under a continuous flow of ropivacaine 0.2% (start flow 4 mL/h, at first postoperative day 1 reduction to 2.5 mL/h). Initial numbness after a start bolus of 10 mL ropivacaine 0.2% was resolved on the first postoperative day. Catheter removal was scheduled for the second postoperative day. After removal of the sterile draping, the responsible pain nurse withdrew the catheter using gentle traction but stopped immediately when she noticed catheter separation (see Figure 1). Accordingly, she informed the responsible consultant, who unfortunately could not remove the indwelling residual steel wire. Notably, the patient complained of pain during gentle traction via the residual wire. Another removal attempt was performed in our post anesthesia care unit under standard monitoring and mild analgosedation using fentanyl 0.1 mg intravenously. Under ultrasound guidance, the residual wire was traced backwards to its final position next to the supraclavicular plexus. Traction of the wire resulted in tissue movements next to the plexus fascia and patient discomfort. The completely removed polyurethane component was visually checked and showed no signs of incisions, kinking or otherwise expected damage. Under sterile conditions, the proximal polyurethane catheter component was cut away. In another attempt, the residual wire was threaded through a 16 G intravenous catheter (Braunuele, B Braun Medical, Melsungen, Germany) and then the catheter was advanced retrogradely through the skin until resistance occurred (~4 cm beneath the skin). Another attempt to remove the indwelling wire through this artificial tunnel under forced traction unfortunately failed again.

Bottom Line: Stimulating catheters are widely used for continuous peripheral nerve block techniques in regional anesthesia.The incidence of reported complications is somewhat similar to that for non-stimulating catheters.Anesthesiologists should strictly avoid catheter shearing during insertion, adhere to the manufacturer's instructions, and take care during catheter removal.

View Article: PubMed Central - PubMed

Affiliation: Department of Anesthesia and Intensive Care Medicine, University Hospital Marburg, Marburg, Germany.

ABSTRACT

Purpose: Stimulating catheters are widely used for continuous peripheral nerve block techniques in regional anesthesia. The incidence of reported complications is somewhat similar to that for non-stimulating catheters. However, as many stimulating catheters contain a coiled steel wire for optimal stimulation, they may cause specific complications.

Clinical features: In this report, we present two cases of complicated removals of stimulating catheters. During both removals, a part of the metal wire was left "decoiled" next to the supraclavicular and interscalene plexus, respectively. The strategies used to determine steel wire localization and a description of the successful removal of these steel wires are included in this report.

Conclusion: Catheter separation and problems with residual metal wire components of stimulating catheters seem to be a rare but specific problem during removal. Anesthesiologists should strictly avoid catheter shearing during insertion, adhere to the manufacturer's instructions, and take care during catheter removal. Manufacturers should focus on technical solutions to avoid rare but relevant complications such as catheter tip decoiling and separation of stimulating catheters during removal.

No MeSH data available.


Related in: MedlinePlus