腰椎硬膜外導管放置時造成導管打結

A Knotted Epidural Catheter during Lumbar Epidural Catheterization

臨床特徵：一個三十七歲男性，因車禍導致右股骨骨折，要進行開放性復位內固定術。病人是以右側躺的姿勢在第二及第三腰椎間，以十八號Tuohy針進行穿刺。導管安全的被放置在針頭末端二十公分記號處。就在將導管回拉到於皮膚十二公分記號處時，導管卡住且無法再將之回拉。在和病人及其家屬討論後，決定以全身麻醉的方式進行手術。在全身麻醉後，以右側躺的姿勢用穩定的力量再次將導管回拉。這一次成功完整的將導管拉出且沒有併發症。討論：關於打結的形成，大部份的作者都相信，如果導管進入硬膜外腔越多，理論上它產生糾結的可能性越高。在這個案例中，我們認為不管皮膚到硬膜外腔的距離為何，如果導管放置在針的末端超過十五公分記號處時，它可能會增加繞圈和打結的形成。因為這表示有五公分長度的導管留置於硬膜外腔，而這會增加導管繞圈和打結的形成。如果導管打結已經確定，則必須向病人解釋，並以下列方式做決定：1. 以不同的姿勢及不同程度的腰椎屈曲，用平穩固定的力量將導管拉出；2. 也可以選擇在導管近端阻塞處，以外科的方式做切除取出。總之導管放置的長度不超過針頭尖端五公分，以減少繞圈和打結的形成，並以穩定的力量將導管拉出，或使用外科的方式。

Clinical Feature: A 37-yr-old male patient presented for ORIF due to right femoral fracture by traffic accident. The patient was positioned in right lateral decubitus. An 18-gauge Tuohy epidural needle was inserted at the L2-L3 interspace. The catheter was at approximately 20 cm mark from the end of the needle. During withdrawal at the 12 cm mark outside the skin, it stuck and could not be withdrawn further. After discussion with the patient and his family, the operation proceeded under general anesthesia. After general anesthesia, the patient was placed in right lateral decubitus and we used a steady force to withdraw the catheter again. This time, the catheter was removed intact with no complications. Discussion: About the knot formation, most authors believe that the more the catheter is advanced into the epidural space, the greater is the theoretical potential of “kinking and knotting” of the catheter. In this case, we think, no matter the distance from the skin to epidural space, if the catheter is inserted past the 15 cm mark at the end of the needle, it may increase the loop and the knot formation. Because it means there is about 5 cm length catheter left in the epidural space and it increases the loop and knot formation.If a knot is demonstrated in the catheter, this should be explained to the patient and a course of action decided upon: 1. Firm, steady traction on the catheter with the patient in various positions and in various degrees of lumbar flexion. 2. Surgical excision may be elected, following the proximal catheter to the point of obstruction. In conclusion, insertion of the catheter should be no more 5 cm beyond the tip of the needle to reduce the loop and knot formation. And remove the knotted catheter with steady force traction or surgically.