A retrograde tunnelling technique for regional anesthesia catheters: how to avoid the skin bridge
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A retrograde tunnelling technique for regional anesthesia catheters: how to avoid the skin bridge Carole Lin, MD . Travis Reece-Nguyen, MD . Ban C. H. Tsui, MD, MSc
Received: 20 September 2019 / Revised: 7 October 2019 / Accepted: 7 October 2019 Ó Canadian Anesthesiologists’ Society 2019
To the Editor, Tunnelling of continuous regional anesthesia catheters has been suggested to provide stability/reduce dislodgement1 and to decrease the infection risk from bacterial colonization, particularly for epidural catheters.2 Despite tunnelling typically involving relatively minimal time and additional equipment, it remains an underutilized technique and is not commonly taught in most training programs. Some tunnelling-related complications have been reported, including the catheter breaking off at the skin3 as well as difficulties extracting the catheter requiring surgical intervention. Thus, it is important to review several key steps of a successful retrograde tunnelling technique that can decrease the potential for catheter damage and minimize the skin bridge (i.e., infection risk from exposing the catheter at the original puncture site) that can occur with more conventional tunnelling methods.4 In the figure and accompanying video, the retrograde tunnelling technique is demonstrated in a porcine model. After placing the catheter at the desired location and depth, the clinician should carefully remove the Touhy regional needle while ensuring that the catheter position remains unchanged. This is accomplished using a looping technique to stabilize the catheter while removing the Electronic supplementary material The online version of this article (https://doi.org/10.1007/s12630-019-01505-6) contains supplementary material, which is available to authorized users. C. Lin, MD T. Reece-Nguyen, MD B. C. H. Tsui, MD, MSc (&) Department of Anesthesiology, Perioperative and Pain Medicine, Lucille Packard Children’s Hospital, Stanford University, School of Medicine, Stanford, USA e-mail: [email protected]
needle with deliberate and equal motions to avoid knotting the catheter while simultaneously maintaining control of the catheter position with pressure at the skin entry site. After adequate local anesthetic infiltration, the subcutaneous tunnelling begins with insertion of the styleted Touhy needle tip while directing its bevel away from the catheter. Using a sterile syringe with its plunger removed as a needle shield, one can protect from any inadvertent skin puncture to the patient and clinician as well as providing counter-pressure to aid the tunnelled Touhy in exiting through the skin. Once the tunnelling needle exits, the stylet of the Touhy needle is removed, and a sterile well-fitted guidewire (e.g., Arrow AW-14732 with outer diameter 0.032 inches/0.81 mm, TeleflexÒ, USA) is inserted through the 17G (inner diameter 0.036 inches/0.91 mm) or 18G (inner diameter 0.032 inches/0.81 mm) Touhy needle. Next, the needle is withdrawn while keeping the guidewire in the subcutaneous tunnel. Using the guidew
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