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Younger JD, Faryami A, Prasad M, Viar D, Menkara A, Tang A, Harris CA. Direct Comparison of Peak Bulk Flow Rate of Programmable Intermittent Epidural Bolus and Manual Epidural Bolus Using a Closed-End Multiorifice Catheter: An Experimental Study. Anesth Analg 2023; 136:1198-1205. [PMID: 36730916 DOI: 10.1213/ane.0000000000006268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The programmable intermittent epidural bolus (PIEB) has been popularized as the optimal delivery technique for labor analgesia. Suggested advantages of this method are less local anesthetic consumption, improved maternal satisfaction, potentially shorter duration of labor, and decreased workload requirements for the anesthesia providers. However, a manual bolus is still routinely used for breakthrough pain when the PIEB is underperforming. METHODS We conducted a laboratory-based study to quantify the flow through a multiorifice epidural catheter using the PIEB setting on an epidural pump compared to the manual epidural bolus. Four syringe volumes, 3, 5, 10, and 20 mL, were selected for this experiment. The flow in a manual bolus was also studied with and without the presence of an epidural catheter filter. A generalized estimating equation analysis was done to compare data between the groups. RESULTS Regardless of the syringe size, there was a several-fold increase in flow when a manual bolus was used compared to a pump-administered dose, with the highest difference in the peak flow rate observed in 3-mL boluses with up to a 12-fold difference, while the difference was, at most, 7-fold in 5-mL and 10-mL boluses. Manual boluses without a filter achieve a mean peak flow rate higher than manual boluses with a filter. CONCLUSIONS Our study found that manual boluses produced a higher flow rate compared to the CADD-Solis epidural pump (Smiths Medical). This study also found that the placement of a particulate filter reduces the flow rates generated while bolusing. Bulk flow rate is directly correlated with induced pressure and solution spread. Because higher bolus pressure has been shown to provide a more efficient distribution of local anesthetic and more efficient pain relief, these results may have impactful clinical significance and will pave the way for future studies.
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Affiliation(s)
- Joshua D Younger
- From the Department of Anesthesiology, Pain Management, and Perioperative Medicine, Henry Ford Health, Detroit, Michigan
| | - Ahmad Faryami
- Department of Biomedical Engineering, Wayne State University, Detroit, Michigan
| | - Monica Prasad
- Department of Medical Education, Wayne State University School of Medicine, Detroit, Michigan
| | - Daniel Viar
- Department of Computer Science and Engineering, University of Toledo, Toledo, Ohio
| | - Adam Menkara
- Department of Biomedical Engineering, Wayne State University, Detroit, Michigan
| | - Amy Tang
- Department of Public Health Science, Henry Ford Health, Detroit, Michigan
| | - Carolyn A Harris
- Department of Chemical Engineering and Materials Science, Wayne State University, Detroit, Michigan
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Eloy A, Tinoco J, Regufe R, Cortez J, Cordeiro L. Epidural Catheter Migration: A Case Report of a CT Scan Examination. Cureus 2022; 14:e30831. [DOI: 10.7759/cureus.30831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2022] [Indexed: 11/05/2022] Open
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Identifying a correctly positioned thoracic epidural catheter for major open surgery. BJA Educ 2020; 20:330-331. [PMID: 33456913 DOI: 10.1016/j.bjae.2020.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2020] [Indexed: 11/22/2022] Open
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Bell DN, O'Connor A, Leslie K. The Influence of Flushing Epidural Catheters before use on Detection of Intravenous Placement: An in Vitro and in Vivo Study. Anaesth Intensive Care 2019; 35:932-8. [DOI: 10.1177/0310057x0703500612] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Undetected intravenous placement of epidural catheters is rare but potentially fatal and no perfect identification method exists. Epidural catheters may be flushed before insertion to identify faulty epidural catheters, or to prime the system with local anaesthetic. We hypothesised that flushing epidural catheters before insertion may delay the detection of intravenous placement. We investigated our theory using both in vitro and in vivo models. The in vitro component examined flowrates in flushed and unflushed epidural catheters, using conditions designed to mimic epidural venous pressure. The in vivo component examined the flow within flushed and unflushed epidural catheters inserted into the forearm veins of 20 anaesthetised patients, using a randomised crossover design. The endpoint utilised for both components was the time taken for frank blood to reach the 20 cm mark on the epidural catheter. Blood flow to the 20 cm mark on the epidural catheter was significantly faster in the unflushed catheters than the flushed catheters, both in vitro and in vivo (in vitro, unflushed median = 18.6 s (range: 18.0 to 20.5 s), flushed 37.6 s (32.6 to 91.2 s), P=0.0009; in vivo, unflushed 9.2 seconds (range 5.0 to 35.3 s), flushed 19.2 s (10.6 to 47.4 s), P=0.003 in vivo). Flushed catheters also demonstrated a greater variability in the range of flowrates. Flushing epidural catheters before insertion may delay the detection of intravenous placement.
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Affiliation(s)
- D. N. Bell
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital and Departments of Chemical and Biomolecular Engineering and Pharmacology, University of Melbourne, Melbourne, Victoria, Australia
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital
| | - A. O'Connor
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital and Departments of Chemical and Biomolecular Engineering and Pharmacology, University of Melbourne, Melbourne, Victoria, Australia
- Department of Chemical and Biomolecular Engineering, University of Melbourne
| | - K. Leslie
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital and Departments of Chemical and Biomolecular Engineering and Pharmacology, University of Melbourne, Melbourne, Victoria, Australia
- Department of Chemical and Biomolecular Engineering, University of Melbourne
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[Epidural anaesthesia: Simulated intravascular test dose with S(+) ketamine, lidocaine and adrenaline. A prospective, randomized, double blind and placebo controlled study]. ACTA ACUST UNITED AC 2014; 62:64-71. [PMID: 25034935 DOI: 10.1016/j.redar.2014.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Revised: 04/03/2014] [Accepted: 04/07/2014] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The use of a test dose in epidural anaesthesia is a safety recommendation. However specificity and sensitivity of the drugs used with this indication have been not conclusive. The main objective of this study was to compare the effectiveness and the adverse effects of a simulated intravascular test dose of adrenaline, lidocaine and S(+)-ketamine. MATERIAL AND METHODS A prospective, randomized, double blinded, placebo controlled study was designed. ASA I patients scheduled for elective surgery were included. These were randomized to the following study groups: S(+)-ketamine 0.5 mg.kg-1 (S+K group), 5% lidocaine 1.5 mg.kg-1 (L5% group), adrenaline 15μg (ADR group), and physiological saline 3 ml (SF group; control group). An evaluation was made during the first 15 minutes after the study drug was administered. Variables including heart rate (HR) systolic and diastolic blood pressure (sBP and dBP), mean arterial pressure (MAP), and SpO2 were recorded at 0 min (baseline) and at 2, 5, 8, 10 and 15 minutes after drug injection. An increase of at least 20 beats per minute (bpm) in relation to the baseline measurement was considered a positive result, as was an increase sBP >15 mmHg. The clinical effects described as related to iv injection of the study drugs recorded were: sedation-hypnosis, dizziness, nystagmus, metallic taste perception, perioral or facial paresthesias, tinnitus, as well as any other effect the patients mentioned. Sensitivity and specificity were calculated as was the percent increase in the parameters in order to see if these were clinically useful. RESULTS A total of 80 patients, 20 per group, were included. The sBP, dBP, and MAP were significantly raised at the 2, 5, 8 and 10 minutes measurements in the S(+)K group compared to the rest of the groups (P<.05), as well as HR in the 2, 5, 8, 10 and 15 minute measurements in the S(+)K compared to the rest of the groups (P<.05). Sensitivity and specificity were high, and significant in the S(+)K group from minute 2 to minute 8 compared with the placebo group, as well as percentage points differences in the same interval. There were significant differences in the incidence of sedation-hypnosis, nystagmus and dizziness, which were more frequent in the S(+)K group. There were no differences in the incidence of metallic taste, perioral and facial paresthesias or tinnitus. The effects in the S(+)K group always occurred before minute 5 after drug injection. CONCLUSION Both lidocaine an adrenaline at the scheduled doses showed low sensitivity and specificity as a simulated iv epidural test dose. S(+)-ketamine could be a feasible marker after accidental iv injection during epidural anaesthesia or analgesia.
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Tensile Strength Decreases and Perfusion Pressure of 3-Holed Polyamide Epidural Catheters Increases in Long-Term Epidural Infusion. Reg Anesth Pain Med 2011; 36:151-5. [DOI: 10.1097/aap.0b013e31820d418e] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Cheong SH, Park DS, Moon SH, Cho KR, Lee SE, Kim YH, Lim SH, Lee JH, Lee KM, Choe YK, Kim YJ, Shin CM. The Aspiration of Injected Air via an Epidural Catheter as an Indicator for Appropriate Placement of the Catheter in the Epidural Space. Korean J Pain 2009. [DOI: 10.3344/kjp.2009.22.2.124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Soon Ho Cheong
- Department of Anesthesiology and Pain Medicine, Pusan Paik Hospital, College of Medicine, Inje University, Busan, Korea
| | - Dae Sik Park
- Department of Anesthesiology and Pain Medicine, Gupo Sungsim Hospital, Busan, Korea
| | - Sung Ho Moon
- Department of Anesthesiology and Pain Medicine, Pusan Paik Hospital, College of Medicine, Inje University, Busan, Korea
| | - Kwang Rae Cho
- Department of Anesthesiology and Pain Medicine, Pusan Paik Hospital, College of Medicine, Inje University, Busan, Korea
| | - Sang Eun Lee
- Department of Anesthesiology and Pain Medicine, Pusan Paik Hospital, College of Medicine, Inje University, Busan, Korea
| | - Young Hwan Kim
- Department of Anesthesiology and Pain Medicine, Pusan Paik Hospital, College of Medicine, Inje University, Busan, Korea
| | - Se Hun Lim
- Department of Anesthesiology and Pain Medicine, Pusan Paik Hospital, College of Medicine, Inje University, Busan, Korea
| | - Jeong Han Lee
- Department of Anesthesiology and Pain Medicine, Pusan Paik Hospital, College of Medicine, Inje University, Busan, Korea
| | - Kun Moo Lee
- Department of Anesthesiology and Pain Medicine, Pusan Paik Hospital, College of Medicine, Inje University, Busan, Korea
| | - Young Kyun Choe
- Department of Anesthesiology and Pain Medicine, Pusan Paik Hospital, College of Medicine, Inje University, Busan, Korea
| | - Young Jae Kim
- Department of Anesthesiology and Pain Medicine, Pusan Paik Hospital, College of Medicine, Inje University, Busan, Korea
| | - Chee Mahn Shin
- Department of Anesthesiology and Pain Medicine, Pusan Paik Hospital, College of Medicine, Inje University, Busan, Korea
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Fegley AJ, Lerman J, Wissler R. Epidural Multiorifice Catheters Function as Single-Orifice Catheters: An In Vitro Study. Anesth Analg 2008; 107:1079-81. [DOI: 10.1213/ane.0b013e31817f1fc2] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Gadalla F, Lee SHR, Choi KC, Fong J, Gomillion MC, Leighton BL. Injecting saline through the epidural needle decreases the iv epidural catheter placement rate during combined spinal-epidural labour analgesia. Can J Anaesth 2003; 50:382-5. [PMID: 12670816 DOI: 10.1007/bf03021036] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
PURPOSE To determine if injecting 10 mL saline before epidural catheter threading (pre-cannulation epidural fluid injection) can decrease the incidence of iv epidural catheter placement during combined spinal-epidural (CSE) labour analgesia. METHODS One hundred healthy women requesting CSE labour analgesia with either fentanyl 20 microg or sufentanil 10 microg were prospectively randomized to receive either no epidural injection (dry group, n = 50) or epidural 10 mL saline injection (saline group, n = 50) before epidural catheter placement. A nylon multiport catheter was then threaded 3-5 cm into the epidural space and the needle was removed. We diagnosed iv catheter placement if blood was freely aspirated, if the mother became tachycardic after injection of epinephrine 15 microg, or if intracardiac air was heard (using ultrasound) after injection of air 1.5 mL. RESULTS Intravenous epidural catheter placement occurred in one saline and ten dry group patients (P < 0.01). No complications of excessive cephalad intrathecal opioid spread (i.e., difficulty swallowing, hypoxemia, or respiratory arrest) occurred. CONCLUSIONS Injecting 10 mL or saline through the epidural needle after intrathecal opioid injection and before threading the catheter significantly decreased accidental venous catheter placement without any apparent increase in complications from excessive cephalad intrathecal opioid spread.
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Affiliation(s)
- Farida Gadalla
- Department of Anesthesiology, Weill Medical College of Cornell University, 525 East 68th Street, New York, NY 10021, USA.
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