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Removing epidural catheters

A guide for nurses

Sawhney, Monakshi, PhD, MN, BScN, NP; Chambers, Sherida, MSN, BSN, RN; Hysi, Feliks, MN, BSN, BS, RN

doi: 10.1097/01.NURSE.0000546459.86617.2a
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Abstract: Short-term epidural analgesia is effective for postoperative pain, procedural pain, trauma pain, and labor pain. This article describes the skills, procedures, and nursing care required for removing a short-term, temporary epidural catheter.

Review the skills and procedures required for nurses who remove short-term, temporary epidural catheters.

Monakshi Sawhney is an assistant professor at Queen's University in Kingston, ON, Canada. Sherida Chambers is a clinical manager at Humber River Hospital in Toronto, ON. Feliks Hysi is a clinical educator at Joseph Brant Hospital in Burlington, ON.

The authors have disclosed no financial relationships related to this article.

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Figure

ANALGESIA DELIVERED by an epidural catheter refers to the administration of opioids and/or local anesthetics into the epidural space by a single or intermittent bolus injection, continuous infusion, or patient-controlled epidural analgesia with or without continuous infusion (see Anatomy of the epidural space).1

Short-term epidural analgesia is administered through a temporary catheter and external infusion device. Long-term administration is provided by either a tunneled catheter and external infusion device or an implanted catheter and implanted refillable infusion device.2 The focus of this article is on short-term, temporary epidural catheters.

Indications for short-term epidural analgesia include the management of postoperative pain, procedural pain, trauma pain, and labor pain.2,3 Short-term epidural catheters may be left in place from a few hours to up to 5 days.2

In patients receiving epidural analgesia, nursing interventions include administration of local anesthetics and/or opioids through the epidural catheter and assessment of the following:2

  • vital signs
  • pain
  • sedation level
  • sensory and motor function
  • adverse reactions
  • signs and symptoms of complications, such as nerve injury
  • insertion site and dressing
  • catheter, tubing connections, and the infusion device.

Nurses may also be permitted to remove epidural catheters. It is important to ensure this skill is supported by your regulatory body and the appropriate policy in your facility. This article describes the required skills and procedure for catheter removal and the corresponding nursing care.

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Requirements before you start

Begin by assessing and managing the patient's pain, and make sure alternative analgesia is available once epidural analgesia is discontinued. An important step is to determine whether the patient is receiving anticoagulation, which may be prescribed to reduce the risks of venous thromboembolism. If this is the case, note the drug, dosage, and time of the last dose. For management guidelines regarding care for patients receiving both epidural analgesia and anticoagulation, follow the facility's policies and procedures or the prescriber's orders for how long anticoagulation must be held before catheter removal. The guidelines from the American Society of Regional Anesthesia and Pain Medicine regarding the management of patients who are concurrently receiving epidural analgesia and anticoagulation is also a good resource.4

Review the patient's coagulation panel results; it is preferred that these be obtained and reported within 24 hours of a scheduled catheter removal. If the lab values are abnormal, do not remove the epidural catheter. Instead, notify the provider responsible for managing the epidural catheter, which is typically the anesthesiologist.5

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Catheter removal

  • Position the patient lying down in a lateral position with the head and shoulders flexed toward the chest, or sitting on the edge of the bed with the head and back flexed forward.6
  • Turn off the epidural infusion, if applicable.
  • Perform hand hygiene and apply clean gloves and any other appropriate personal protective equipment.
  • Carefully remove the tape or other device that is securing the epidural catheter to the skin and remove the dressing.
  • Grasp the epidural catheter at the insertion site and gently, slowly, and steadily withdraw it at a 90-degree angle to the skin surface.6,7

If you encounter resistance, do not apply more force, as this may damage or break the catheter. Instead, reposition the patient by increasing flexion and reattempt removal. It is also recommended to place patients in the same position as they were at the time of insertion.8

If you encounter too much resistance or the patient experiences any unusual symptoms such as pain or numbness, stop the removal attempt, cover the free end of the catheter and the insertion site with sterile gauze, and notify the responsible provider.

  • After a successful catheter removal, immediately examine the tip of the catheter to ensure it is intact. The tip should have a solid, dark-colored marking.
  • Assess the catheter insertion site for signs and symptoms of bleeding, hematoma, or infection, including erythema, exudate, and pain or tenderness.9
  • Clean the site as per facility policies and procedures, and apply a sterile adhesive dressing, which can usually be removed within 24 hours.
  • Document the date and time of catheter removal, the condition of the catheter tip, the presence of any drainage or bleeding at the insertion site, the patient's response to the procedure, and any difficulty with removal. Also document whether you had to notify the prescriber and any other prescribed interventions that were performed.
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Potential complications

Complications that can occur during epidural catheter removal include breakage, entrapment, knotting, and disruption.3 For example, excessive force or tension during removal may result in catheter sheering or breakage.10 In the event of breakage, asymptomatic patients are managed with imaging and follow-up regarding potential complications; symptomatic patients require surgical removal of the catheter.11

Other complications include hematoma and infection.5,9,12-14 Spinal epidural hematoma (SEH) is a serious complication, with an estimated incidence ranging from 0 to 2.25 per 10,000 epidurals.13-15 Signs and symptoms include a progressive loss of sensation or motor function in the lower extremities, bowel and/or bladder dysfunction, and back pain.5,9,13 Bowel and/or bladder dysfunction is a late sign of SEH.11 If SEH is suspected, urgent MRI or computed tomography is required; if SEH is detected, urgent surgical removal is required.5

Site infection is another potentially serious complication. Early signs and symptoms of epidural site infection include back pain, fever, headache, and erythema.9 Later signs include stiff neck, radiating pain, photophobia, loss of motor function, and confusion. Management of infection includes consultation with a neurologist and/or an infectious disease specialist.9

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Ongoing care

After catheter removal, continue to assess for signs and symptoms of possible complications such as SEH or infection. Instruct patients to report any new symptoms such as lower extremity weakness, paresthesia, or back pain immediately.5,9,12

Monitor the patient for adverse drug reactions related to epidural medication. If the patient received an opioid, monitor for sedation and respiratory depression.1,2 If the patient was administered a local anesthetic, monitor for local anesthetic toxicity for up to 6 hours after catheter removal.16

Short-term epidural analgesia is commonly used in pain management, and nurses must be prepared to manage catheters as required. This includes assessing and providing care to patients during epidural infusion. It may also include the safe removal of epidural catheters and post-removal monitoring.

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Anatomy of the epidural space1

The epidural space is the area between the dura mater and the vertebral wall. The dura is adherent to the bone above the foramen magnum. In contrast, an actual or true epidural space exists below the foramen magnum posterior and lateral to the spinal cord that extends down the length of the spinal canal. This space is small in the cervical region and larger in the sacral region. The epidural space contains fat as well as arteries and a venous plexus.

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REFERENCES

1. Norris M. Neuraxial anesthesia. In: Barash PG, Cullen BF, Stoelting RK, et al., eds. Clinical Anesthesia. 8th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2017.
2. Pasero C, Eksterowicz N, Primeau M, Cowley C. Registered nurse management and monitoring of analgesia by catheter techniques: position statement. Pain Manag Nurs. 2007;8(2):48–54.
3. Shah T, Rubenstein A. Disruption of a wire-reinforced epidural catheter upon removal: importance of having a set protocol. Int J Obstet Anesth. 2016;26:89–91.
4. Narouze S, Benzon HT, Provenzano D, et al Interventional spine and pain procedures in patients on antiplatelet and anticoagulant medications (second edition): guidelines from the American Society of Regional Anesthesia and Pain Medicine, the European Society of Regional Anaesthesia and Pain Therapy, the American Academy of Pain Medicine, the International Neuromodulation Society, the North American Neuromodulation Society, and the World Institute of Pain. Reg Anesth Pain Med. 2018;43(3):225–262.
5. Ladha A, Alam A, Idestrup C, Sawyer J, Choi S. Spinal haematoma after removal of a thoracic epidural catheter in a patient with coagulopathy resulting from unexpected vitamin K deficiency. Anaesthesia. 2013;68(8):856–860.
6. Kim YR, Choi JW, Sim WS, Lee CJ, Chang C. The influence of patient position on withdrawal force of lumbar epidural catheters after total knee arthroplasty: a randomized trial. J Clin Anesth. 2016;34:98–104.
7. Higgins D. How to remove epidural catheters. Nurs Times. 2006;102(12):28–29.
8. Chen JL, Cherng CH, Chan SM, et al Difficult removal of an epidural catheter in the anterior epidural space. Acta Anaesthesiol Taiwan. 2010;48(1):49–52.
9. Kupersztych-Hagege E, Dubuisson E, Szekely B, et al Epidural hematoma and abscess related to thoracic epidural analgesia: a single-center study of 2,907 patients who underwent lung surgery. J Cardiothorac Vasc Anesth. 2017;31(2):446–452.
10. Molina-Garcia RA, Munoz-Martinez AC, Hoyos-Pescador R, De La Torre-Espinosa R. Retained epidural catheter : a rare complication. Report of two cases. Rev Col Anest. 2017;45(S1):4–7.
11. Reena, Vikram A. Fracture of epidural catheter: A case report and review of literature. Saudi J Anaesth. 2017;11(1):108–110.
12. Umegaki T, Hirota K, Ohira S, et al Rapid development of a spinal epidural hematoma following thoracic epidural catheter removal in an esophageal carcinoma surgical patient: a case report. JA Clin Rep. 2016;2(1):37
13. Bateman BT, Mhyre JM, Ehrenfeld J, et al The risk and outcomes of epidural hematomas after perioperative and obstetric epidural catheterization: a report from the Multicenter Perioperative Outcomes Group Research Consortium. Anesth Analg. 2013;116(6):1380–1385.
14. Cook TM, Counsell D, Wildsmith JA. Major complications of central neuraxial block: report on the third national audit project of the Royal College of Anaesthetists. Br J Anaesth. 2009;102(2):179–190.
15. Choi S, Brull R. Neuraxial techniques in obstetric and non-obstetric patients with common bleeding diatheses. Anesth Analg. 2009;109(2):648–660.
16. Neal JM, Barrington MJ, Fettiplace MR, et al The Third American Society of Regional Anesthesia and Pain Medicine Practice Advisory on Local Anesthetic Systemic Toxicity: Executive Summary 2017. Reg Anesth Pain Med. 2018;43(2):113–123.
Keywords:

Epidural analgesia; epidural catheters; epidural space; spinal epidural hematoma

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