Leaking Catheters

LEAKING IS NOT  NORMAL OR  REASONABLE

     I have talked with many people who do blocks -and some who do LOTS of blocks that are not bothered by leaking peripheral nerve catheters. “They just leak” is what they say like it doesn’t matter really and it can’t be helped anyway. Some (forgive my directness) don’t think that their catheters leak (much) when they actually do. Do you know how often and how much your catheters leak? Sometimes I think that I am being too dogmatic in my approach to how I dress my catheters (or other little ‘particulars’ that I have), but recent experience has brought me back to what years of experience has taught me on this point. First, catheters should not leak…ever. Second, it does matter for several reasons.

     To keep catheters from leaking [nonmember]…

 

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, I always use Dermabond (there are a few similar products around, but I have not gotten around to testing them myself) at the entry site and along a small length of the catheter, then after it has dried a bit, I apply Steri-strips over the entry site and along this same length of catheter. Benzoin and whatever else you may find around is not going to cut it with any regularity. There are some points about where to locate the Tegaderm edges and a few other points that will help, but I will go into that some other time. The point is that Dermabond is the trick…and it is worth the money, the effort and extra 15 seconds necessary to add it. It keeps the ‘back track’ from reaching the skin, loosening the Tegaderm and whatever combination of Steri-strip plus ‘sticky stuff’ you thought was going to work. Once this happens, all stickiness ends, and the Tegaderm allows a track of local anesthetic to follow the catheter to its edge and drip on the sheets. The only solution here is to redress the bandage (ahem, with Dermabond). The only catheter I have had to leak in years is one where I was teaching a student (mostly watching) and they had the Tegaderm on before I noticed that the Dermabond had been omitted. I though again “maybe I’m too dogmatic about this”. Sure enough, the next day, it leaked, and the patient was hurting. This leads me to my second point.

     I will start with the least concerning circumstance and consequences of leaking catheters. You have an inpatient with an electronic hospital pump with a bag of local that can be replaced over and over that starts to leak. Once the ‘back track’ has overcome the resistance at the skin as described above, half of your analgesia is pouring onto the bed now. Well, who cares; we’ll just increase the rate, add boluses more and change the sheets, right? Fine, but now you are wasting even more (kind of hard to get these days) Ropivicaine, and the patient is still not receiving optimal analgesia (and I bet you they are still hurting). Further, changing the dressing risks catheter dislodgement. Next, let’s consider that you use a disposable pump for the same patient. Yes, you can (run up again and) bolus them along the way, but the reservoir will run out quicker. You will either have to cheat the patient on the length of analgesia, add significantly more P.O. (and I.V.) opioid side-effects or have the hospital buy another pump for them. Now let’s send this patient home with a disposable pump with the same problem. Now they hurt more, have no ‘big gun’ opioids available and the local is ruining their designer sheets. “I thought this was supposed to be some awesome pain control solution, doc.” Now you look like you are pioneering a ‘not so helpful and just a bigger expense’ pain control solution, and your hospital support is dwindling a bit more. Beyond all of that, if there is some blood-tinged fluid as above, you are going to get phone calls with frantic patients worried that they are bleeding through the catheter.  Lastly, I think it is outrageously unlikely to actually have an infection, but there are patients that are at particular risk. For whatever it is worth, Dermabond creates an anti-bacterial shield versus colonization from the skin flora.

     Let me state that I have no relationship with whoever sells Dermabond or any of the other ‘similar to Dermabond’ products. Further, I have seen ‘non-Dermabonded’ sites last for three days on occasion. The only other solution that I have found that will also work to date (almost as well) is Derma-Flex. That being said, in my opinion, we are going through a lot of trouble and expense to add this modality for it be suboptimal or to fail outright. This is especially true when we alter a patient’s recovery plan by sending them home (again, with no I.V. pain relief option that is otherwise what would be needed) with something that has the ‘possibility’ of working well. This is what I have seen. This is what nurses have told me emphatically about my patients versus other anesthesiologist’s patients that don’t do what I do. Don’t let your patient get home and have to deal with something like the picture at the top of this post

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