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Correspondence |
Montreal General Hospital, McGill University Health Centre, Montreal, Canada, E-mail: de_tran{at}hotmail.com
To the Editor:
We report the case of a stimulating infraclavicular catheter that was retained and subsequently cut, requiring a surgical incision for removal. Consent for publication of personal information was obtained from the patient according to our local institutional guidelines.
A 52-yr-old American Society Anesthesiologists class 1 woman had an open reduction and internal fixation of her left radius under general anesthesia. Postoperatively she was given narcotics for analgesia but experienced severe nausea and vomiting. She agreed to the insertion of a continuous infraclavicular brachial plexus block for pain control. Using Wilson’s landmarks,1 an Arrow StimucathTM Continuous Nerve catheter (Arrow International, Reading, PA, USA) was placed uneventfully in the left infracoracoid area. The catheter was advanced easily under stimulation 4 cm beyond the tip of the needle. Its proximal end was tunnelled under the skin leaving a small skin bridge at the initial insertion site of the needle. The patient received a bolus of 30 mL bupivacaine 0.25% followed by a continuous infusion (10 mL·hr–1 ropivacaine 0.2%) with excellent pain relief.
The following day, the local anesthetic infusion was stopped to allow a neurological assessment of the operated limb by the surgeon. As her pain was well controlled with acetaminophen and codeine, the patient requested that her catheter be removed. After experiencing resistance upon removal of the catheter, the patient’s nurse cut the catheter at the skin bridge. When she pulled on the distal end of the catheter, the sheath came off, leaving the stimulating wire in place. We were then notified. After assessment, the patient was taken to the operating room. With fluoroscopy, the wire was visualized and knotting was ruled out. Under local anesthesia, a small incision was made and the wire removed (Figure).
Inability to remove perineural catheters due to knotting or breakage has been described after femoral,2 fascia iliaca,3 sciatic,4 and axillary5 blockade. Most of these cases required surgical extraction for catheter removal. We are the first to describe a retained stimulating infraclavicular catheter. The latter became separated from its stimulating wire after being cut. In this institution nurses on the ward remove all nerve catheters. We feel that it is important to instruct the nursing staff and ambulatory patients never to cut stimulating perineural catheters. Furthermore, patients should be told to contact the anesthesia department immediately if they encounter any difficulty during catheter removal.
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1 Wilson JL, Brown DL, Wong GY, Ehman RL, Cahill DR. Infraclavicular brachial plexus block: parasagittal anatomy important to the coracoid technique. Anesth Analg 1998; 87: 870–3.
2 Lee BH, Goucke CR. Shearing of a peripheral nerve catheter. Anesth Analg 2002; 95: 760–1.
3 Offerdahl MR, Lennon RL, Horlocker TT. Successful removal of a knotted fascia iliaca catheter: principles of patient positioning for peripheral nerve catheter extraction. Anesth Analg 2004; 99: 1550–2.
4 MacLeod D. Knotted peripheral nerve catheter (Letter). Reg Anesth Pain Med 2003; 28: 487–8.[Medline]
5 Hubner T, Gerber H. Knotting of a catheter in the plexus brachialis. A rare complication (German). Anaesthesist 2003; 52: 606–7.[Medline]
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