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In Response: Comment on “Assessing the Utility of Fluoroscopy for Epidural Catheter Placement: What End Points Are Important?”

Yeager, Mark P. MD; Parra, Michelle C. MD; Sites, Brian D. MD

doi: 10.1213/ANE.0000000000002468
Letters to the Editor: Letter to the Editor
Free

Published ahead of print September 12, 2017.

Department of Anesthesiology and Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, mark.p.yeager@hitchcock.org

Department of Anesthesia, University of Iowa Hospitals and Clinics, Iowa City, Iowa

Department of Anesthesiology and Orthopedics, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire

Published ahead of print September 12, 2017.

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To the Editor

Dr Grocott has raised an important consideration regarding the definition of epidural catheter “failure.”1 Our letter sites a decrease in the thoracic epidural catheter “failure rate” from 25% to 2% when fluoroscopy is used. The article to which these data refer was entitled, more accurately, “Fluoroscopic guidance increases the incidence of thoracic epidural catheter placement within the epidural space: a randomized trial.”2 Thus, we are in agreement with Dr Grocott on this point. Correct anatomical location of an epidural catheter does not guarantee successful utilization of the technique. The definition of epidural catheter “failure” might be better defined as either mechanical (nonepidural location, unintended dislodgment) or pharmacological (inadequate pain control, unacceptable side effects).

Regarding the intentional placement of an epidural catheter to either a right- or a left-sided location, we may not have fully described the role of fluoroscopy. We use real-time fluoroscopy during epidural catheter placement such that repeated images are taken while the catheter is advanced in the epidural space to ensure that it is ultimately located at the desired vertebral level and that it is located either midline or, if desired, either to the right or left of midline. With this approach, catheters can often be “steered” and laterality obtained. In any case, this option should not obscure the broader points that correct anatomical placement of an epidural catheter is more reliably achieved with fluoroscopy and that correct placement, in itself, is but one step in the process of providing effective epidural analgesia.

Mark P. Yeager, MDDepartment of Anesthesiology and MedicineDartmouth-Hitchcock Medical CenterLebanon, New Hampshiremark.p.yeager@hitchcock.org

Michelle C. Parra, MDDepartment of AnesthesiaUniversity of Iowa Hospitals and ClinicsIowa City, Iowa

Brian D. Sites, MDDepartment of Anesthesiology and OrthopedicsDartmouth-Hitchcock Medical CenterLebanon, New Hampshire

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REFERENCES

1. Grocott H. Assessing the utility of fluoroscopy for epidural catheter placement: what end points are important? Anesth Analg. 2017;125:1823.
2. Parra MC, Washburn K, Brown JR, et al. Fluoroscopic guidance increases the incidence of thoracic epidural catheter placement within the epidural space: a randomized trial. Reg Anesth Pain Med. 2017;42:17–24.
Copyright © 2017 International Anesthesia Research Society