Previous section | Next section

Removal of an epidural catheter

Pre‐procedural considerations

Before an epidural or intrathecal catheter is removed, it is essential to consider the clotting status of the patient's blood. If the patient is fully anticoagulated, a clotting profile must be performed and advice sought from the medical staff as to when the catheter can be removed. If the patient is receiving a prophylactic anticoagulant, the following guidelines are recommended (Harrop‐Griffiths et al. [74]).

Low‐dose, low‐molecular‐weight heparin

If this is given once daily, the epidural catheter should be removed at least 12 hours after the last injection and several hours prior to the next dose. The timing will depend on the manufacturer's recommended guidelines; for example, for tinzaparin (Leo Laboratories Ltd), it is recommended that epidural or spinal catheters are removed a minimum of 4 hours before the next dose.

Unfractionated heparin

The epidural catheter should be removed following local guidelines and the advice of the anaesthetic or pain management team.

Procedure guideline 10.5

Epidural catheter removal

Post‐procedural considerations

Catheter‐associated spinal epidural haematomas can occur during catheter placement or removal. Their incidence has been reported to range from 2 to 20 cases per 100,000 epidural procedures (Li et al. [96]; Rosero and Joshi [162]). The development and progression of haematomas associated with epidural anaesthesia are relatively slow and are generally characterized by symptoms such as impaired motor function (paraplegia) and sensory abnormalities, and moderate to severe back pain also occurs in many cases (Umegaki et al. [182]). The time course of spinal epidural haematoma development after catheter removal is variable, and it is reported that paraplegia can occur as early as 1 hour after catheter removal, with some patients developing symptoms after more than 24 hours (Ladha et al. [91], Mahapatra et al. [101]). The consequences of an epidural haematoma may be permanent paralysis below the level of the haematoma.

For this reason, it is recommended that patients continue to be vigilantly monitored after the epidural catheter has been removed so that prompt action can be taken if there is any evidence of haematoma development (see step 12 in Procedure guideline 10.5: Epidural catheter removal).

Table 10.10 Prevention and resolution (Procedure guidelines 10.2, 10.3 and 10.5)

Problem	Cause	Prevention	Action
Headache	Dural puncture caused during the insertion procedure.	Expertise of practitioner inserting the epidural	Bedrest: headache will be less severe if patient lies flat. Provide replacement fluids either intravenously or orally to encourage formation of CSF. Administer analgesics for headache. If headache does not settle, contact the anaesthetic team, who may consider an epidural blood patch to seal the puncture ( Sachs and Smiley [163]).
Sedation and respiratory depression (opioid toxicity) Circumoral tingling and numbness, twitching, convulsions and apnoea (local anaesthetic toxicity)	If the catheter migrates into a blood vessel, signs of opioid or local anaesthetic toxicity can occur.	Expertise of practitioner inserting the epidural. Careful monitoring of the patient to detect early symptoms.	Stop epidural infusion. Contact pain or anaesthetic team, or summon emergency assistance. Treat the patient for complications of opioid or local anaesthetic overdose. If necessary, give oxygen.
Apnoea, profound hypotension and unconsciousness	If an epidural catheter migrates from the epidural space into the intrathecal space to the CSF, the analgesic solution may reach as high as the cranial intrathecal space. If this occurs, the respiratory muscles are paralysed together with the cranial nerves, resulting in apnoea, profound hypotension and unconsciousness. This is because intrathecal doses are calculated as one‐tenth of the epidural dose and migration from the epidural space to the intrathecal space leads to a drug overdose.	Expertise of practitioner inserting the epidural. Careful monitoring of the patient to detect early symptoms.	Stop the epidural infusion. Summon emergency assistance. Prepare emergency equipment to support respiration and ventilate lungs. Prepare emergency drugs and intravenous fluids and administer as directed. Prepare equipment for intubation.
Back pain and tenderness and nerve root pain with sensory and motor weakness	Epidural haematoma.	Assessment of coagulation status before insertion and removal of the epidural/intrathecal catheter.	Urgent neurological assessment. Carry out an MRI or CT scan to accurately diagnose whether there is nerve or spinal cord compression. If a haematoma is diagnosed, urgent surgery may be required to relieve the pressure ( Hewson et al. [77]). To avoid haematoma on removal of epidural in patients treated with prophylactic anticoagulants, see local guidelines for timing of removal.
Back pain and tenderness May have redness and purulent discharge from catheter exit site May also develop nerve root signs with neuropathic pain and sensory/motor weakness	Epidural abscess.	Maintain aseptic technique when accessing the epidural/intrathecal analgesic system. Monitor temperature regularly and check insertion site for evidence of infection.	If the epidural catheter is still in situ, remove the tip and send it for culture and sensitivity. Treat the patient with antibiotics. Carry out an MRI or CT scan and refer the patient for urgent neurosurgery to prevent paraplegia ( Hewson et al. [77]).
Headaches, fever, neck stiffness and/or photophobia	Meningitis.	Maintain aseptic technique when accessing the epidural analgesic system. Monitor temperature regularly.	Assist the anaesthetist or doctor to obtain a CSF sample for microbiology analysis. Initiate antibiotic therapy as per hospital policy. Consider non‐pharmacological measures for symptom management, for example dim lights ( Macintyre and Schug [99]).
Low block	Catheter potentially dislodged. The height of the block has fallen below the upper limit of the surgical incision or pain site.	Regular assessment of sensory block.	Increase the rate if prescribed. Contact the anaesthetic team or acute pain team for review and consideration of a bolus to re‐ establish the block or to reposition the epidural catheter.
High block (i.e. T4 or above)	The rate may be too high. The position of the catheter may have moved.	Regular assessment of sensory block.	Stop the epidural. Contact the anaesthetic team, acute pain team or emergency team if the patient is unable to breathe. Sit the patient upright. Administer oxygen if needed. The pain or anaesthetic team will provide advice on when to restart the epidural infusion.
Unilateral block	The position of the catheter may have moved.	Regular assessment of sensory block.	Roll the patient onto their side with no block (the analgesia may move with gravity). Contact the pain or anaesthetic team to review the epidural for consideration of adjusting the epidural catheter or giving a bolus dose.
No block	The catheter may have been dislodged.	Regular assessment of sensory block.	Contact the pain or anaesthetic team to review the epidural. They can consider adjusting the epidural catheter or giving a bolus dose. The patient may need to have an alternative method of analgesia if a block cannot be established and/or pain becomes an issue (note that patients may have no pain if they have an opioid running alongside a local anaesthetic; therefore, it can be possible for the patient to have no block and have minimal pain).

CSF, cerebrospinal fluid; CT, computed tomography; MRI, magnetic resonance imaging.