Journal of Clinical and Diagnostic Research. 2018 Aug, Vol-12(8): UC11-UC14 11 11 DOI: 10.7860/JCDR/2018/32787.11938 Original Article Anaesthesia Section A Clinical Audit on Technical Difficulties during Epidural Catheter Placement NITIN CHOUDHARY 1 , ANJU BHALOTRA 2 , KAVITA RANI SHARMA 3 , GUNJAN MANCHANDA 4 ABSTRACT Introduction: Epidural catheter placement is a routinely performed invasive procedure conducted by anaesthesiologist’s world over. A functional epidural catheter improves, not only the quality of anaesthesia but also patient satisfaction. Placing an epidural catheter is a skill which has its own set of technical difficulties. Aim: To conduct an audit to study the common technical difficulties faced during epidural catheter placement and their management. Material and Methods: The audit was conducted by evaluating the responses to a structured, self-administered questionnaire consisting of 10 questions distributed to post-graduate students, senior residents and consultants working in the Department of Anaesthesiology and Intensive care at a tertiary care centre in New Delhi during June 2017. The questions pertained to the respondent’s years of experience in Anaesthesiology and their response and management of the common technical difficulties encountered during epidural catheter placement. Results: Out of a total of 111 respondents, 64.86% had less than 5 years and 13.51% had more than 10 years of experience in the field of anaesthesiology. Almost 92% used air for locating the epidural space by the Loss Of Resistance (LOR) technique. Varied responses were obtained regarding difficulties in catheter advancement and management of presence of CSF or blood in the catheter and regarding the use and benefits of placing an intrathecal catheter and the duration of keeping an intrathecal catheter in situ. Only 2.70% had experienced shearing of an epidural catheter and in all the cases, this was during catheter removal in the postoperative period. Conclusion: There are no standard guidelines available for management of technical difficulties encountered during epidural catheter placement and this audit identified certain lacunae in knowledge and management of these difficulties. INTRODUCTION Epidural catheter placement is one of the most routinely performed procedures in anaesthesia practice. However, placing an epidural catheter is an invasive procedure with its own set of complications [1]. Although the advent of ultrasound has helped anaesthesiologists in identifying the epidural space in patients with difficult anatomical landmarks, it is not used routinely for all epidural cannulations. Through the observations from the present study at the centre made us realise that some of the practices followed by working anaesthesiologists could prove harmful to the patient. We reviewed the literature and to the best of our knowledge there has been no audit conducted regarding technical difficulties faced during epidural catheter placement. There are no standard guidelines formulated by any anaesthesiologist society giving recommendations on management of technical difficulties faced during an epidural catheter placement. The most commonly encountered technical problems like an inadvertent dural puncture or a bloody tap while threading a catheter can be managed in a lot of different ways [1]. However, there is no consensus on which technique is better over the other which not only creates confusion but also puts the patient at risk of epidural related complications which otherwise can be warded off. Whilst these difficulties are usually handled by the concerned anaesthesiologist performing the procedure depending on their level of experience and clinical judgement, improper management of these problems may result in considerable postoperative morbidity. Hence, the audit was conducted in a tertiary care hospital where the working anaesthesiologists were questioned about the difficulties faced during epidural catheter placement and how they circumvented these difficulties. MATERIAL AND METHODS An audit was conducted at tertiary care hospital in New Delhi, in order to analyse the technical difficulties encountered by anaesthesiologists while placing a lumbar epidural catheter in an unanaesthetised patient in sitting position. A structured, self- administered questionnaire pertaining to technical difficulties while epidural catheter placement was distributed to all post-graduate students (n=29), senior residents (n=72) and consultants (n=30) working at a single tertiary care hospital. In the study, the 1 st year post-graduate students and the consultants who formulated the questionnaire from the audit were excluded. The anonymity of the person filling the proforma was ensured. The questionnaire was prepared and validated by a departmental committee comprising of four senior anaesthesiologists with more than 10 years of experience in the field of anaesthesiology and consisted of ten questions pertaining to the technical problems encountered during epidural catheter placement with primary focus on the most common problems namely dural puncture, intravascular placement and catheter shearing and the management of these problems. The audit was undertaken to assess the knowledge and current practices in anaesthesia and, if required, suggest pertinent modifications to current practice after reviewing the literature in order to prevent complications in the future. The first question was on the years of experience that the respondent had in the field of anaesthesiology. The second question enquired about the preferred medium (air, saline, air and saline mixture) for locating the epidural space using the Loss of Resistance (LOR) technique. The next three questions were related to accidental dural puncture either by the epidural needle or epidural catheter and management of the same. Keywords: Catheter migration, Dural puncture, Regional anaesthesia, Shearing