RU2759872C1 - Method for securing the epidural catheter after passing thereof in the subcutaneous canal - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to anesthesiology and intensive care, and can be used for securing an epidural catheter by forming an intracutaneous loop and a cutaneous loop of the epidural catheter. A large subcutaneous canal is formed from the site of epidural access to the first exit of the epidural catheter to the skin. An epidural catheter is passed in the small subcutaneous canal by means of a modified spinal needle with an outer diameter of 0.52 mm or 0.45 mm, wherein said canal begins at a point located 5 mm lateral to the point of the first exit of the epidural catheter to the skin from the large subcutaneous canal. When forming the small subcutaneous canal, the modified spinal needle with the epidural catheter secured thereon is passed under the skin to a distance of 10 mm in the caudal direction, followed by passing the epidural catheter secured on the modified spinal needle into the lumen between the skin surface and the cutaneous section of the epidural catheter located on the skin surface between the point of the first exit of the epidural catheter to the skin and the point of entry of the epidural catheter into the small subcutaneous canal, thus forming an intracutaneous loop of the epidural catheter. The modified spinal needle with the epidural catheter secured thereon is then inserted into the lumen formed between the skin surface and the epidural catheter located between the point of the second exit of the epidural catheter to the skin and the point of entry of the epidural catheter into the small subcutaneous canal, thus forming a cutaneous loop of the epidural catheter. The two loops of the epidural catheter - the intracutaneous loop and the cutaneous loop - are therein formed after the epidural catheter is passed in the subcutaneous canal at the point of exit of the epidural catheter from the subcutaneous canal.

EFFECT: method ensures reliable securing of the epidural catheter, preventing external dislocation thereof, due to formation of loops.

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Description

The invention relates to medicine, namely to anesthesiology and intensive care. Neuroaxial anesthesia methods such as epidural anesthesia, spinal anesthesia and combined spinal-epidural anesthesia are methods without which it is impossible to imagine performing surgical interventions in many areas of surgery and traumatology. Highly traumatic surgical interventions objectively require prolonged postoperative pain relief. This task is successfully dealt with by the constant, for several days, the introduction of local anesthetic into the epidural space for the purpose of analgesia in the area of surgical intervention (Koryachkin V.A., Strashnov V.I. Spinal and epidural anesthesia. St. Petersburg Medical Publishing House, 2000 .). The technical problem solved by the invention is to create a reliable method for fixing an epidural catheter (EC), which is able to prevent its external and internal dislocation. The absence of EC dislocation allows for long-term high-quality postoperative epidural analgesia, and this, in turn, reduces the risk of complications in the postoperative period and creates comfortable conditions for patients who have undergone surgery. EC fixation on the skin of the lumbar region is carried out in three ways. The first method is fixation with adhesive tape. This method has shown its unreliability and a large percentage of cases with clinically significant EC dislocation. The second way is to use special locking devices "Lockit", "Epi-Fix" and "Perifix". Fixation of EC is more reliable, but this method of fixation leads to an increase in the cost of the technique of epidural anesthesia and combined spinal-epidural anesthesia, and changing such a device is a rather complicated and time-consuming manipulation, in which EC dislocation can occur. The third method is EC fixation in the subcutaneous canal. With EC fixation in the subcutaneous canal, EC displacement was noted only in 10% of cases (Coupe M., Al-Shaikh B., 1999; Carrie L. E. S., 2000). The less traumatic is the method of conducting and fixing EC in the subcutaneous canal, the more reliable the fixation will be and the fewer cases of EC dislocation. The use of a modified spinal needle (ISI) with an outer diameter of 0.52 mm or 0.45 mm for conducting and fixing EC in the subcutaneous canal allows this to be done less traumatically (A.P. Marchenko, O.N. Yamshchikov, S.A. Emelyanov. The method of conducting an epidural catheter in the subcutaneous canal during two-segment spinal-epidural anesthesia (patent RU No. 2 727 234 С 1 class IPC A 61 19/00 from 21.07.2020 https://doi.org/10.20310/2658-7688-2020- 2-4 (8) -7-13) .After EC in the subcutaneous canal, it is fixed on the skin with an adhesive tape. Despite the fixing properties of the subcutaneous location of EC, dislocation cannot be completely prevented. M. Tripathi et M. Pandey proposed a method of EC fixation in the subcutaneous canal with the formation of a cutaneous EC loop before it is carried out in the subcutaneous canal. the method contributes to a more reliable fixation of EC in comparison with the method with the imposition of an EC loop on the skin at the site of the epidural access, but without tunneling. With this method, there were fewer cases with external dislocation of EC (3% versus 21%) and fewer cases with internal dislocation (12% versus 27%). The use of this method significantly reduced the number of cases with external dislocation of EC, but could not prevent internal dislocation of EC. The authors themselves explain this by the fact that the EC loop located in front of the entrance to the subcutaneous canal facilitated easier penetration of EC inside (Tripathi M, Pandey M. Epidural catheter fixation: subcutaneous tunneling with a loop to prevent displacement. // Anaesthesia. - 2000. - V .55. - P.1113-1116. Doi: 10.1046 / j.1365-2044.2000.01547-2.x. PMID: 11069341).

We propose a method for EC fixation after it is carried out in the subcutaneous canal with the formation of an intracutaneous and cutaneous EC loop, which should prevent its external and internal dislocation. To form an intracutaneous and cutaneous EC loop, a spinal needle in a modified version G 25 with an outer diameter of 0.52 mm or a G 26 needle with an outer diameter of 0.45 mm is used, with the help of which EC was carried out in the subcutaneous canal from the epidural access site in the lateral direction from the medial line. The modification of the spinal needle consists in breaking off the pavilion of the needle: take the spinal needle as close as possible to the needle pavilion with a surgical clamp and take the needle pavilion with the index and thumb of the right hand and move the needle pavilion up and down until the needle pavilion is disconnected from the needle. After that, the EC is fixed on a modified spinal needle (ISI): the proximal end of the ISI (the one that is closer to the needle pavilion) is inserted into the EC lumen at a distance of 5 mm to 10 mm. MSI with an outer diameter of 0.52 mm or MSI with an outer diameter of 0.45 mm allows performing EC in the subcutaneous canal and forming an intracutaneous and cutaneous EC loop with little trauma.

Method description: After EC with the help of ISI in the large subcutaneous canal (5) from the epidural access site in the lateral direction from the medial line, the ISI skin is punctured with an outer diameter of 0.52 mm or 0.45 mm with EC fixed on it in place (8), located at a distance of 5 mm lateral to the place of the first EC exit to the skin (6). MSI with EC fixed on it is carried out under the skin in the caudal direction at a distance of 10 mm to the place of the second EC exit on the skin (10). Formed a small subcutaneous canal (9) (Fig. 1). Then the ISI with the EC fixed on it is removed from the small subcutaneous canal (9) (Fig. 2). Subsequently, the EC is extended to its full internal location under the skin in the large subcutaneous canal (5) from the epidural access site (4) to the first exit of the EC on the skin (6). This is the first stage in the formation of an intradermal EC loop (Fig. 4). Subsequently, MSI with EC fixed on it is carried out into the lumen between the skin surface and the cutaneous EC (7) located on the skin surface between the place of the first EC exit on the skin (6) and the EC entry into the small subcutaneous canal (8). This is the second, final stage of the formation of the intradermal EC loop (Fig. 5, Fig. 6). Subsequently, to form an EC cutaneous loop (11), an MSI with EC fixed on it is carried out into the lumen between the skin surface and EC located on the skin surface between the place of the second EC exit to the skin (10) and the entry point of the epidural catheter into the small subcutaneous canal (8 ). Thus, a cutaneous EC loop is formed (11). The intradermal EC loop performs the main fixing function that prevents EC dislocation. In case of an unintentional or deliberate attempt to remove the EC, the intradermal loop will tighten (nodulation occurs), which will not allow the EC to be removed from the epidural space without the participation of a healthcare professional. This is second order insurance. The cutaneous loop is designed to prevent EC dislocation during traction on the EC during movement of the patient in the lumbar and thoracic spine (flexion, extension of the back). The EC cutaneous loop allows the EC to move without dislocation during the patient's natural normal motor activity. This is insurance against the deployment of the first order EC. That is, at first, the cutaneous loop will prevent dislocation during the patient's natural physiological motor activity, and then if a significant traction effect is applied to the EC by the patient intentionally or unintentionally, in which it can be removed from the epidural space, nodulation of the EC intradermal loop will occur, which will prevent dislocation and prolapse of the catheter from the epidural space. Only a medical professional can remove the EC when it becomes necessary (the end of prolonged epidural analgesia) by cutting the epidural catheter located on the skin surface between the site of the first exit of the epidural catheter and the entry of the epidural catheter into the small subcutaneous canal with scissors. ...

FIG. 1 shows how a modified spinal needle with an epidural catheter fixed to it is guided caudally 10 mm under the skin in a small subcutaneous canal up to the second exit of the epidural catheter to the skin.

FIG. 2 depicts the extraction of a modified spinal needle with an epidural catheter fixed on it from the small saphenous canal.

FIG. 3 shows how a modified spinal needle with an epidural catheter fixed on it is inserted into the lumen between the skin surface and the cutaneous section of the epidural catheter located on the skin surface between the site of the first exit of the epidural catheter on the skin and the site of the epidural catheter entry into the small subcutaneous canal.

FIG. 4 shows the end of the formation of the intradermal loop of the epidural catheter.

FIG. 5 shows the final view of the formed intradermal and cutaneous epidural catheter loop.

FIG. 6 shows a diagram of the intradermal and cutaneous loop of an epidural catheter.

A clinical example is given as an embodiment of the invention.

1. Patient L., 79 years old. Diagnosis: Main: Closed pertrochanteric fracture of the left femur with displacement of fragments. Concomitant: Ischemic heart disease. Atherosclerotic heart disease. Hypertension stage 3. Arterial hypertension of 1 degree (medically achieved). The risk of cardiovascular complications of 4 degrees. Chronic heart failure stage 2 A (Functional class 2). Overweight. Physical status according to ASA 3 Art. The operation was performed: "Open reduction of a pertrochanteric fracture of the left femur, osteosynthesis of a DHS fracture." Anesthetic management: "Combined two-level spinal - epidural anesthesia with the introduction and fixation of an epidural catheter in the subcutaneous canal using a modified spinal needle and with the formation of an intradermal loop and an epidural catheter cutaneous loop." In a sitting position in aseptic conditions, after three times treatment of the skin of the lumbar region with 70% alcohol solution, local anesthesia of the skin with a solution of Lidocaine 5 mg / ml - 20 mg was carried out in the intervertebral space L3-L4, as well as in the intervertebral space L2-L3. In the intervertebral space L3-L4, puncture and catheterization of the epidural space were performed. In the L2-L3 interval, the subarachnoid space was punctured with a spinal needle G 25 with an outer diameter of 0.52 mm. A hyperbaric solution of Bupivacaine 5 mg / ml - 20 mg was introduced into the subarachnoid space. The needle has been removed. Executed and fixed an epidural catheter in the subcutaneous canal at an angle of 90 ° to the sagittal plane at a distance of 75 mm in the lateral direction from the epidural access site. The canal under the skin was made with a modified spinal needle G 25 with an outer diameter of 0.52 mm. Subsequently, in order to enhance the fixation of the epidural catheter, after anesthesia of the skin with a solution of Lidocaine 5 mg / ml - 25 mg at the site of the first exit of the epidural catheter on the skin, an intracutaneous and cutaneous loop of the epidural catheter was formed. Treatment with an antiseptic solution was performed and sterile adhesive tape was applied to the skin at the site of the epidural access, puncture of the subarachnoid space and at the site of the intracutaneous and cutaneous loops of the epidural catheter. Postoperative anesthesia was carried out in the trauma department after a test dose with a solution of Lidocaine 20 mg / ml - 4.0 ml (80 mg) for 4 days with a solution of Ropivacaine 2 mg / ml at a dose of 12 mg / hour. Treatment with an antiseptic solution of the epidural catheter fixation site on the skin and replacement of aseptic stickers was carried out once a day. There were no infectious complications or dislocation of the epidural catheter.

Claims (2)

1. A method of fixing an epidural catheter by forming an intradermal loop and a cutaneous loop of an epidural catheter, which consists in forming a large subcutaneous canal from the epidural access site to the first exit of the epidural catheter onto the skin, using a modified spinal needle with an outer diameter of 0.52 mm or 0 , 45 mm epidural catheter in the small saphenous canal, which begins at a place located 5 mm lateral from the site of the first exit of the epidural catheter to the skin from the large saphenous canal, during the formation of the small saphenous canal, a modified spinal needle with an epidural catheter fixed on it is passed under the skin at a distance of 10 mm in the caudal direction, after which an epidural catheter, fixed on a modified spinal needle, is inserted into the lumen between the skin surface and the cutaneous section of the epidural catheter located on the skin surface between the site of the first outlet of the epidural catheter onto the skin and the entry point of the epidural catheter into the small subcutaneous canal, thus forming an intradermal loop of the epidural catheter, after which the modified spinal needle with the epidural catheter fixed on it is inserted into the lumen formed between the skin surface and the epidural catheter located between the site of the second exit of the epidural catheter to the skin and the entry point of the epidural catheter into the small subcutaneous canal, thus forming the epidural catheter cutaneous loop. 2. The method according to claim. 1, characterized in that the formation of two loops of the epidural catheter - the intradermal loop and the cutaneous loop is carried out after the epidural catheter is inserted in the subcutaneous canal at the exit site of the epidural catheter from the subcutaneous canal.

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