Epidural dislodgements Department Data

Dr. Farah Jafri

Anesthetist

Al Razi Hospital

Introduction

Emphasis in textbooks on location and technique of epidural

Not much data on fixation.

Most techniques based on experience.

OUR EXPERIENCE

• AUDITS over 6 month periods

• Over 3 years

• 2010- Sept 2010 to Feb 2011

• 2011- March 2011 to August 2011

• 2012- march 2012- August 2012

2010 Month No of cases Dislodged %

Sept 2010 28 2 7.00%

Oct 35 2 4.60%

Nov 43 2 3.00%

Dec 33 1 3.00%

Jan 2011 42 0 0.00%

Feb 46 1 2.00%

227 8

Overall dislodgement rates- 3.35%

2010

sept--2010

oct nov dec jan--2011

feb

Series1 7.00% 4.60% 3.00% 3.00% 0.00% 2.00%

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

8.00%

Axi

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DISLODGEMENT RATES 2010

2011

No. of cases Dislodged %

March 44 2 4.50% April 59 2 3% May 36 2 7% June 46 5 10% July 31 1 3% Aug 25 4 12.50%

241 16

Overall Dislodgement rate- 6.64%

Mar-11

Apr-11 may june july aug

Series1 4.50% 3% 7% 10% 3% 12.50%

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

14.00% D

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Dislodgement Rates 2011

2012 Month no. No of cases Dislodged %

March 38 2 5.20%

April 50 6 12%

May 47 2 4.20%

June 25 3 12%

July 17 2 11.70%

Aug 34 7 20.00%

211 22

Overall dislodgement rates- 10.44%

Mar-12

Apr-12

may june july aug

Series1 5.20% 12% 4.20% 12% 11.70% 20.00%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

Axi

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Dislodgement rates 2012

• Most of dislodgements were after 24- 48 hours of catheter use.

• In 2012 audit,

• Time of dislodgement

On day 3- 12 /22

On day 2- 10/22

• Site of dislodgement

Patient end- 16/22

Filter -6/22 cases.

REVIEW OF LITRATURE

• Effectiveness of acute postoperative pain management.

Clinical bottom line S Dolin et al. Effectiveness of acute postoperative pain management: I.

Evidence from published data. British Journal of Anaesthesia 2002 89: 409-423.

• Epidural catheter displacement from 32 papers with 13,629 patients.

• The overall mean incidence of premature catheter dislodgement was 5.7% (95% confidence interval 4.0 to 7.4%).

Our rates-

• 2010- 3.35%

• 2011- 6.64%

• 2012- 10.4%

• Delayed epidural catheter removal: the impact of postoperative coagulopathy.

Tsui Anaesth Intensive Care. 2004 Oct;32(5):630-6

• 413 patients • Accidental epidural catheter dislodgement

occurred in 29 patients (7%)

• No statistical diff from our data.( P= 0.07) 2010-2011

Having a fixation on fixation!

How to fix this problem of fixation?

?

What are other people doing?

Dr Shaukat, Dr Abhay et al in BJA 2010

• Conventional method - covering the epidural insertion site with tegaderm followed by fixing the catheter to the back up to the shoulder using mefix dressing.

• NOVEL method- epidural catheter was fixed at the insertion site using the blue sponge included in the epidural pack then covered with tegaderm which edges were fixed using Op-tape

Dr Shaukat, Dr Abhay et al in BJA 2010

Dr Shaukat, Dr Abhay et al in BJA 2010

• 87 patients

• Group 1, 69 patients, conventional method,

• Group 2 18 patients novel technique

• In 24 hours Group1, (39.1%) dislodged

• Group2, (5.5%),

• After 24 hours (18.8%) dislodged in Group1,

• no catheter had been dislodged in Group2.

COMMENT ON BULKY COVERINGS

• I would like to commend the authors for trying to achieve an epidural fixation method which is better than

existing devices, comfortable for the patient and cheaper than commercially available alternative devices. • However, I have some concerns regarding the method which has been

described. Using the blue sponge seems to obscure the epidural insertion site and therefore it would be

impossible to visualise any redness around the site. Secondly,

any displacement of the catheter at the insertion site would also

not be easy to pick up. Any leakage of drugs would be asborbed by the sponge and therefore may delay diagnosis of a catheter which had

become misplaced. If blood was absorbed onto this sponge, it would

provide a hidden medium for the growth of micro-organisms. At least with most other devices, or even just a single tegaderm or other sticking plastic material, the insertion site is more visible.

LOCK IT DEVICE

Safe practices in epidural catheter tunneling Anaesthesiol Clin Pharmacol. 2012 Jan-Mar; 28(1):

• 200 patients thoracic or lumbar epidural tunnelling led to significantly decreased catheter migration,

• 83% functioning catheters after 3 days

• 67% functioning without tunneling

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A suggested fixation

Suggestions?