BackgroundBackgroundBackgroundBackground• Accidental disconnection of an indwelling epidural catheter from the filter is not uncommon

• There is no quoted incidence rate in the literature

• Usually this leads to the disconnected catheter lying on the patient’s skin, clothing or bedclothes, exposing the patient to potential risk of infection

• The anaesthetist is then faced with the decision whether to remove the catheter completely and reinserting it if necessary or cutting &/or cleaning the end of the catheter & reconnect

• To date, the 2004 guideline on good practice1 (revised to best practice in 20102) advises that local protocols & guidelines should include the management of accidental catheter disconnection (recommendation 8.4) but it only states that “the decision to remove or keep the epidural must be made by the anaesthetist who will take into account all risks and benefits to the patient”

Management of Epidural Catheter Disconnection in the North Western Deanery, UKEkambaram R*, Lie J† & Brocklehurst I‡* Specialty Trainee (ST6), Lancashire Teaching Hospitals NHS Foundation Trust† Specialty Trainee (ST7), Pennine Acute Hospitals NHS Trust, UK‡ Consultant, Pennine Acute Hospitals NHS Trust, UK

AimsAims• To gain an insight on how anaesthetists in the North Western Deanery manage epidural catheter disconnection in obstetric & non-obstetric settings

• To explore the rationale behind current evidence

• To provide recommendations on its management

MethodsMethods• A survey was sent via email to all practicing anaesthetists and pain nurses in the North Western Deanery using Google form

• Nov ’11 to 2 ’12 & June ’13 to Sept ’13 (2 phases)

• Responders were asked questions on management of epidural disconnection (between catheter and connector) in situations when witnessed or not, time limits, in obstetric patients and difficult epidurals and local trust policy awareness

ResultsResults• Total of 132 responses: 128 anaesthetists & 4 pain nurses • 44% being consultants

•Reconnecting epidural (time limited):

• 20% never reconnect

• 37% reconnect if <30mins

• 12% reconnect even if >30mins

• 34% said other (antiseptic clean, cut & reconnect) (depends if contamination occurred)

•If epidural insertion was difficult , would you change the management?

• 21% would reconnect instead of removing

• 38% would not change management

• 46% said other (depend on clinical situation) (consider risk vs benefit)

DiscussionDiscussion• If not witnessed, 44% would abandon and either reinsert a new epidural or change to a different regime

• 19% would only reconnect if immediately witnessed and 42% would reconnect within 30 minutes

• Most indicated their management would not change for obstetric patients or those with difficult epidurals

• Awareness of local trust policy is poor

• Personal experience, influences what individual practice. There is lack of scientific evidence and recommendation for common practice

ConclusionConclusion• This is clearly a grey topic with huge variation of management strategies

• In-vitro study showed that as long as fluid was static, no bacteria was detected > 13 inches from end of catheter after 8hrs from deliberate exposure of tips to pathogens3

• Recent evidence indicating the cutting of 12cm of epidural catheter is enough to minimise infection risk4 could play a huge role in removing good working epidurals unnecessarily &exposing patients to risks of another epidural, especially those on thromboprophylaxis5

ReferencesReferences1. Royal College of Anaesthetists, Royal College of Nursing, Association of Anaesthetists of Great Britain and Ireland, British Pain Society, European Society of Regional Anaesthesia & Pain Therapy. Good Practice in the Management of Continuous Epidural Analgesia in the Hospital Setting, November 2004. www.aagbi.org/publications/guidelines/docs/epidanalg04.pdf

2.Royal College of Anaesthetists, Royal College of Nursing, Association of Anaesthetists of Great Britain and Ireland, British Pain Society, European Society of Regional Anaesthesia & Pain Therapy. Best practice in the management of epidural analgesia in the hospital setting, November 2010 http://www.rcoa.ac.uk/system/files/FPM-EpAnalg2010_1.pdf

3.Epidural Catheter reconnection. Safe and unsafe practice. Langevin PB, Gravenstein N, Lengevin SO, Gulig PA.

4. Walker JC & Boddu K. Is 12cm the magic number to shorten regional anaesthesia catheters after disconnection? International Journal of Obstetric Anaesthesia. 2013; 22: S32

5. Wysowski D, Talarico L, Bacsanyi J, Botstein P. Spinal and epidural hematoma and low molecular weight heparin. N Engl J Med 1998; 338: 1774

Results (Cont.)Results (Cont.)

Witnessed vs Unwitnessed Disconnection

between epidural catheter & connector

• Would you act differently in Obstetric patients?

• Yes 5%

• No 48%

• 17% don’t do Obstetrics

• 30% said other

•Local Hospital policy

• Only 11% were aware of policy

• 43% did not know

• 18% said they had no policy