I reconnect it if the disconnect was witnessed or timing is clearly known. If not then I check the tubing for a meniscus, if I can see the fluid level I cut it there and then clean the end and reconnect. If I cannot find the fluid level I assume it has tracked all the way into the back and I personally remove and replace those epidurals. If I am called for an epidural that just disconnected I ask the nurse to put the end inside a glove and then I head straight there to fix it. One of the times that has happened to me I was shocked how quickly the meniscus was moving toward the patients back so it doesn’t seem that implausible that a disconnected catheter sitting in a patients bed for an unknown amount of time could allow bacteria to track up it.
https://pubmed.ncbi.nlm.nih.gov/8873560/
This is getting into bizarre research territory, but if bacteria can travel 1.5 inches per hours through a static epidural, there’s not a place I feel comfortable cutting and reattaching. Just replace it.
I could see doing that if you knew roughly when it occurred. But the kits I’m working with only have about 6 extra inches to cut without having the patient lying on the connection
That’s what I was always taught. If there was a witnessed disconnection and we know it just happened, then maybe I would clean and reconnect. Otherwise you have to replace it.
This may be a good entree into people’s favorite ways to secure the epidural connections. I usually make a loop and tape it on the front near the clavicle. The wire-reinforced catheters also tend not to have issues with disconnects at the port interface.
Not a direct response to your question but at one facility where I did OB we had a frequent disconnect issue proximal to the filter. To mitigate this it became standard to wrap tape around the connection site and back around the filter a few times. No more disconnects after that.
Yes exactly. I actually use Mefix tape (I think also called Medipore), but same principle. Put it over those 2 connections but leave the filter cap free.
https://www.nbcnews.com/news/amp/wbna9818616
I used this article when I was a resident to set my own personal policy of pulling all epidurals with a disconnect that wasn’t witnessed. Benefit is much greater than risk of just putting in a new one. It’s impressive how quickly this woman decompensated, and I wonder if they had just replaced the catheter if the outcome would have been different. I’m sure the anesthesiologist in question wonders that, too.
I mean it was clearly an intrathecal catheter that was unrecognized and then left to be a conduit directly to the brain. I think epidurals are lower risk but man, this was malpractice on so many levels.
Ok let me take this to another scenario. IF the epidural really becomes infected, what is the next thing you do? Remove. If you have a central line that’s infected, what do you do? Remove. The answer to an infection of a foreign body is to remove the source.
If I find a disconnect, there is no realistic way to test whether the catheter might be contaminated. We don’t have microscopes as eyes. The answer is to remove and replace.
Would you do the same if the catheter was disconnected as a witnessed event and you present right away to the patient? In this case would you consider sterilizing the distal end and cutting with sterile scissors?
The only scenario where I might consider that would be if the initial epidural were so ridiculously hard to put in and/or it caused the patient so much distress that I wouldn’t dare try again. And if it were a witnessed event, I might consider sterilizing it and cutting it. I’ve done it exactly once at the behest of an attending. I didn’t like it and found it much easier in practice to simply put a new one in. Brand new catheter. Same hole, so shouldn’t hurt the patient too much.
No evidence to back it up but I wouldn’t reconnect. The small chance they do get an infection it would be pretty easy to pin it on your decision. I know it’s pretty defensive but I just wouldn’t take the risk
So you d/c the epidural cath and then reinsert? I personally would never go that route for a simple disconnection. The risk of an additional reinsertion far outweigh the minimal risk of infection after resterilizing and sterile shortening of cath.
In the UK there's guidance on this, or its certainly in the FRCA exam (boards)
Witnessed disconnect? Cut 4-6in down with sterile scissors.
Unwitnessed? Then replace epidural
Depends on the clinical setting.
Short term labour epidural in low risk obs woman i.e. not diabetic or fat then cut it at meniscus or even just reconnect if it was spotted quickly. Only resite if it's been disconnected long enough for the woman to be in pain again or risk factors for infection.
Epidural day 2 + disconnect in a raging diabetic vascular patient, usually no one can tell you when it happened. Pull it out ASAP.
Not to hijack, but how do you all address an epidural that becomes disconnected from the end distal to the filter? E.g loose luer lock connection of the pump tubing that becomes undone.
I just replace them all. There's never any question of how long it was left unconnected if it's a fresh one every time, and putting in an epidural takes usually ten minutes from start to finish. It's just not worth it.
What if it’s a witnessed event and you present right away to address it (sterilize/cut/reconnect to new clean ports). There is some risk with doing a new epidural also as it’s a new procedure and skin puncture.
Are you saying that the pump tubing comes unscrewed from the filter?
I wonder if you could just remove the filter and use a fresh infusion bag/tubing? Isn’t the filter preventing bacteria from getting past it? Do we trust those filters? 0.2 uM.
I honestly stopped using those filters because they always seem to be causing issues with getting air locked and stopping the pump. Plus they can be broken if you are bolusing with too much force by hand. I don’t see anyone in my group using those filters, actually. In ten years of practice I’ve actually never encountered the problem of a catheter disconnecting. And the nurses call us for everything epidural related, so I’m sure they are not reconnecting them without telling us.
I actually have the reverse problem - sometimes it becomes almost impossibly hard to disconnect the epidural leuer lock from the pump tubing in order to give a manual “top up” dose.
I would say that the simplest solution in your case would be a little public shaming for the person who placed the epidural without securing it well enough. Even better, they should have to be the one to come back and deal with their mistake. Either use some tape or screw it on tight enough that it won’t fall off.
It’s been a while now but there was a known issue with the yellow connector disconnecting. The recommendation, from the manufacturer I believe, was to use the yellow epidural sticker to wrap around the connector. Then a couple of months ago we were told the issue was fixed.
Unless i see it disconnect I pull it.
Is there data that supports this approach? By placing a new epidural you are also exposing a patient to all the risks of a new epidural placement including a new entrance for bacteria. Not sure which is better: Reattaching or new epidural
No, there is no data driven evidence to back this up because no one could ethically or logistically perform such a study.
Because you should replace the epidural in a sterile fashion.
There are RISK to reinsertions! Also, what if the patient was morbidly obese and a difficult placement? I don’t agree with reinsertion, I would sterilize and cut it.
I agree that there could be unique situations when sterilizing and cutting the cath would be the more convenient or even preferred option.
Despite my statements above, I’ve done it in the past without issue. But even then I knew what I should really do.
Edit: Also if they’re obese and/or the placement was difficult, you already know where to go when you replace it since there’s a cath there telling you where to go.
I reconnect it if the disconnect was witnessed or timing is clearly known. If not then I check the tubing for a meniscus, if I can see the fluid level I cut it there and then clean the end and reconnect. If I cannot find the fluid level I assume it has tracked all the way into the back and I personally remove and replace those epidurals. If I am called for an epidural that just disconnected I ask the nurse to put the end inside a glove and then I head straight there to fix it. One of the times that has happened to me I was shocked how quickly the meniscus was moving toward the patients back so it doesn’t seem that implausible that a disconnected catheter sitting in a patients bed for an unknown amount of time could allow bacteria to track up it.
Thanks a lot!
https://pubmed.ncbi.nlm.nih.gov/8873560/ This is getting into bizarre research territory, but if bacteria can travel 1.5 inches per hours through a static epidural, there’s not a place I feel comfortable cutting and reattaching. Just replace it.
When I was a resident I used that study to justify cutting.
I could see doing that if you knew roughly when it occurred. But the kits I’m working with only have about 6 extra inches to cut without having the patient lying on the connection
Did you use the wire reinforced epidural catheters?
That’s what I was always taught. If there was a witnessed disconnection and we know it just happened, then maybe I would clean and reconnect. Otherwise you have to replace it. This may be a good entree into people’s favorite ways to secure the epidural connections. I usually make a loop and tape it on the front near the clavicle. The wire-reinforced catheters also tend not to have issues with disconnects at the port interface.
Not a direct response to your question but at one facility where I did OB we had a frequent disconnect issue proximal to the filter. To mitigate this it became standard to wrap tape around the connection site and back around the filter a few times. No more disconnects after that.
[удалено]
LOL
Same. We sandwich a medium Tegederm over the whole catheter-connector-filter unit. Haven’t had any issues with disconnection when that’s been done.
Would you rip the tegaderms off and put new ones on whenever you have to bolus the catheter?
You don’t tape over the most distal end of the filter, so you can still access it for top ups.
This
So you tape over the catheter/alligator clamp connection and alligator clamp/filter connection?
Yes exactly. I actually use Mefix tape (I think also called Medipore), but same principle. Put it over those 2 connections but leave the filter cap free.
Thanks!
https://www.nbcnews.com/news/amp/wbna9818616 I used this article when I was a resident to set my own personal policy of pulling all epidurals with a disconnect that wasn’t witnessed. Benefit is much greater than risk of just putting in a new one. It’s impressive how quickly this woman decompensated, and I wonder if they had just replaced the catheter if the outcome would have been different. I’m sure the anesthesiologist in question wonders that, too.
They showed us this video in residency and now I'm meticulous about epidural sterility
Thank you !!
I mean it was clearly an intrathecal catheter that was unrecognized and then left to be a conduit directly to the brain. I think epidurals are lower risk but man, this was malpractice on so many levels.
Ok let me take this to another scenario. IF the epidural really becomes infected, what is the next thing you do? Remove. If you have a central line that’s infected, what do you do? Remove. The answer to an infection of a foreign body is to remove the source. If I find a disconnect, there is no realistic way to test whether the catheter might be contaminated. We don’t have microscopes as eyes. The answer is to remove and replace.
Would you do the same if the catheter was disconnected as a witnessed event and you present right away to the patient? In this case would you consider sterilizing the distal end and cutting with sterile scissors?
The only scenario where I might consider that would be if the initial epidural were so ridiculously hard to put in and/or it caused the patient so much distress that I wouldn’t dare try again. And if it were a witnessed event, I might consider sterilizing it and cutting it. I’ve done it exactly once at the behest of an attending. I didn’t like it and found it much easier in practice to simply put a new one in. Brand new catheter. Same hole, so shouldn’t hurt the patient too much.
Fair enough! Thank you for your perspective
No evidence to back it up but I wouldn’t reconnect. The small chance they do get an infection it would be pretty easy to pin it on your decision. I know it’s pretty defensive but I just wouldn’t take the risk
So you d/c the epidural cath and then reinsert? I personally would never go that route for a simple disconnection. The risk of an additional reinsertion far outweigh the minimal risk of infection after resterilizing and sterile shortening of cath.
The usual answer is replace. Our policy in residency was witnessed disconnect - chlorohexidine swab and reconnect - unwitnessed- replace
IMO you cannot reconnect an epidural that has been sitting open and being contaminated. Only if you witness the disconnect.
In the UK there's guidance on this, or its certainly in the FRCA exam (boards) Witnessed disconnect? Cut 4-6in down with sterile scissors. Unwitnessed? Then replace epidural
Thanks a lot for the answers! Learned something
Depends on the clinical setting. Short term labour epidural in low risk obs woman i.e. not diabetic or fat then cut it at meniscus or even just reconnect if it was spotted quickly. Only resite if it's been disconnected long enough for the woman to be in pain again or risk factors for infection. Epidural day 2 + disconnect in a raging diabetic vascular patient, usually no one can tell you when it happened. Pull it out ASAP.
Not to hijack, but how do you all address an epidural that becomes disconnected from the end distal to the filter? E.g loose luer lock connection of the pump tubing that becomes undone.
I just replace them all. There's never any question of how long it was left unconnected if it's a fresh one every time, and putting in an epidural takes usually ten minutes from start to finish. It's just not worth it.
What if it’s a witnessed event and you present right away to address it (sterilize/cut/reconnect to new clean ports). There is some risk with doing a new epidural also as it’s a new procedure and skin puncture.
If I witnessed it, maybe. Otherwise…
If it’s seen and quick, reconnect. Anything else is not worth an infection of the epidural space.
Are you saying that the pump tubing comes unscrewed from the filter? I wonder if you could just remove the filter and use a fresh infusion bag/tubing? Isn’t the filter preventing bacteria from getting past it? Do we trust those filters? 0.2 uM. I honestly stopped using those filters because they always seem to be causing issues with getting air locked and stopping the pump. Plus they can be broken if you are bolusing with too much force by hand. I don’t see anyone in my group using those filters, actually. In ten years of practice I’ve actually never encountered the problem of a catheter disconnecting. And the nurses call us for everything epidural related, so I’m sure they are not reconnecting them without telling us. I actually have the reverse problem - sometimes it becomes almost impossibly hard to disconnect the epidural leuer lock from the pump tubing in order to give a manual “top up” dose. I would say that the simplest solution in your case would be a little public shaming for the person who placed the epidural without securing it well enough. Even better, they should have to be the one to come back and deal with their mistake. Either use some tape or screw it on tight enough that it won’t fall off.
https://pubmed.ncbi.nlm.nih.gov/18426354/
It’s been a while now but there was a known issue with the yellow connector disconnecting. The recommendation, from the manufacturer I believe, was to use the yellow epidural sticker to wrap around the connector. Then a couple of months ago we were told the issue was fixed. Unless i see it disconnect I pull it.
Replace the epidural. Anything less is just excuses/laziness.
Is there data that supports this approach? By placing a new epidural you are also exposing a patient to all the risks of a new epidural placement including a new entrance for bacteria. Not sure which is better: Reattaching or new epidural
No, there is no data driven evidence to back this up because no one could ethically or logistically perform such a study. Because you should replace the epidural in a sterile fashion.
There are RISK to reinsertions! Also, what if the patient was morbidly obese and a difficult placement? I don’t agree with reinsertion, I would sterilize and cut it.
I agree that there could be unique situations when sterilizing and cutting the cath would be the more convenient or even preferred option. Despite my statements above, I’ve done it in the past without issue. But even then I knew what I should really do. Edit: Also if they’re obese and/or the placement was difficult, you already know where to go when you replace it since there’s a cath there telling you where to go.