Can the preuse check of epidural set detect all manufacturing defects?

Dear Editor, Placement of an epidural catheter is a routine practice to provide anesthesia/analgesia in different surgical procedures and painful conditions.[1] The preuse check of the epidural catheter set is routinely advocated to detect any manufacturing defect in the set.[2] We would like to share our recent encounter of a manufacturing defect in the epidural catheter, which was missed during the preuse check and identified only after its placement in the epidural space. A 67-year-old female patient, belonging to the American Society of Anesthesiologists (ASA) class II, was scheduled for fixation of fracture shaft femur. In the OR, standard monitoring was attached, and the optimum position for combined spinal epidural (CSE) anesthesia was achieved after the placement of an ultrasound-guided femoral nerve block. Meanwhile, the preuse check of the CSE set (Espocan®; B. Braun, Melsungen, Germany) was done, and the catheter was flushed with saline. The epidural space was identified by a loss of resistance to saline, and using a needle-through needle technique, 0.5% bupivacaine heavy (2.5 ml) was injected into the intrathecal space. The epidural catheter was threaded and fixed at 10 cm mark. After placement, injection of saline through the catheter filter assembly showed a jet of saline coming out of a defect situated at around 25 cm from the filter [Figure 1a]. Replacing the catheter was not possible without a new puncture as the epidural needle was already withdrawn. Fortunately, the length of the catheter from the leak point to the skin was sufficient for the fixation of the filter at the patient's neck. The part of the catheter between the filter and the leak point was cut, and the filter was connected to the outer end of the epidurally placed catheter [Figure 1b]. On reinjecting saline through the catheter filter assembly, no spill or resistance was noted [Figure 1c]. The epidural infusion of the local anesthetic solution was started during the surgery and continued for the next 72 h for postoperative analgesia without any leakage.Figure 1: (a) Injection of saline through the catheter filter assembly and jet of saline coming out of a small defect in the epidural catheter (black arrow). (b) The cut part of the catheter. (c) Reattachment of the filter with the remaining fixed epidural catheterA number of manufacturing defects have been reported in the epidural catheter, and most of them were detected during the preuse check.[3-5] It is possible that the catheter might get sheared while removing the epidural needle after catheter placement. However, in our case, the needle was smoothly removed over the catheter without causing trauma to it. Therefore, we presume that the defect was already there before placement and it was missed during the preuse check, possibly because of the lesser injection pressure required to flush the catheter when its tip was open to the air. The requirement of higher injection pressure after catheter placement in the epidural space might have opened the small defect in the catheter and the consequent saline spill through it. We advocate that the functioning of the CSE kit should be ensured by flushing the epidural catheter using higher injection pressure. Following the incident, we started performing the preuse check using higher injection pressure by manually occluding the catheter holes, so as to detect the smaller defects. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Support was obtained solely from institutional and/or departmental sources. Conflicts of interest There are no conflicts of interest.