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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 ...
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%
F...
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...
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...
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%
Disl...
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 3...
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%
AxisTit...
• 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
Fil...
REVIEW OF LITRATURE
• Effectiveness of acute postoperative pain
management.
Clinical bottom line
S Dolin et al. Effectiven...
• The overall mean incidence of premature
catheter dislodgement was 5.7% (95%
confidence interval 4.0 to 7.4%).
Our rates-...
• Delayed epidural catheter removal: the
impact of postoperative coagulopathy.
Tsui
Anaesth Intensive Care. 2004 Oct;32(5)...
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...
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 no...
COMMENT ON BULKY COVERINGS
• I would like to commend the authors for trying to achieve an epidural fixation method which i...
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...
ge
A suggested fixation
Suggestions?
Epidural dislodgements Audit Al Razi hospital Kuwait
Epidural dislodgements Audit Al Razi hospital Kuwait
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Epidural dislodgements Audit Al Razi hospital Kuwait

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This is an audit I had done as Coordinator of acute pain service at Al Razi Hospital Kuwait. Through this I was able to draw attention to the rising rate of dislodgement and the technique of fixation was changed.

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Epidural dislodgements Audit Al Razi hospital Kuwait

  1. 1. Epidural dislodgements Department Data Dr. Farah Jafri Anesthetist Al Razi Hospital
  2. 2. Introduction Emphasis in textbooks on location and technique of epidural Not much data on fixation. Most techniques based on experience.
  3. 3. OUR EXPERIENCE • AUDITS over 6 month periods • Over 3 years
  4. 4. • 2010- Sept 2010 to Feb 2011 • 2011- March 2011 to August 2011 • 2012- march 2012- August 2012
  5. 5. 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%
  6. 6. 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% AxisTitle DISLODGEMENT RATES 2010
  7. 7. 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%
  8. 8. 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% DislodgementRates Dislodgement Rates 2011
  9. 9. 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%
  10. 10. 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% AxisTitle Dislodgement rates 2012
  11. 11. • Most of dislodgements were after 24- 48 hours of catheter use.
  12. 12. • 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.
  13. 13. 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.
  14. 14. • 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%
  15. 15. • 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
  16. 16. Having a fixation on fixation! How to fix this problem of fixation? ?
  17. 17. What are other people doing?
  18. 18. 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
  19. 19. Dr Shaukat, Dr Abhay et al in BJA 2010
  20. 20. 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.
  21. 21. 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 drugswould be asborbed by the sponge and therefore may delay diagnosis of a catheter which had become misplaced. If bloodwas 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.
  22. 22. LOCK IT DEVICE
  23. 23. Safe practices in epidural catheter tunneling Anaesthesiol Clin Pharmacol. 2012 Jan-Mar; 28(1):
  24. 24. • 200 patients thoracic or lumbar epidural tunnelling led to significantly decreased catheter migration, • 83% functioning catheters after 3 days • 67% functioning without tunneling
  25. 25. ge
  26. 26. A suggested fixation
  27. 27. Suggestions?

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