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.

1. Epidural dislodgements
Department Data
Dr. Farah Jafri
Anesthetist
Al Razi Hospital

2. Introduction
Emphasis in textbooks on location and
technique of epidural
Not much data on fixation.
Most techniques based on experience.

3. OUR EXPERIENCE
• AUDITS over 6 month periods
• Over 3 years

4. • 2010- Sept 2010 to Feb 2011
• 2011- March 2011 to August 2011
• 2012- march 2012- August 2012

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

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. 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. • 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. • 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. Having a fixation on fixation!
How to fix this problem of fixation?
?

17. What are other people doing?

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. Dr Shaukat, Dr Abhay et al in BJA 2010

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. 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.

23. LOCK IT DEVICE

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

26. • 200 patients thoracic or lumbar epidural
tunnelling led to significantly decreased
catheter migration,
• 83% functioning catheters after 3 days
• 67% functioning without tunneling

27. ge

28. A suggested fixation

29. Suggestions?