Tunneled Epidural Catheter for Long Term use for Cancer Pain

Anatomy

As mentioned in earlier chapters, the epidural space continues from foramen magnum superiorly to the sacrococcygeal membrane inferiorly. Epidural space contains fat, blood vessels, and connective tissues (Stoelting and Miller 2000). Epidural catheter can be placed at any level in the lumbar, thoracic, or cervical level. Infusion can be delivered at either level to help pain in cancer patients. Tunneled catheter is more advantageous than non-tunneled catheter because if infection occurs at the exit site, the infection will be far from the epidural

Table 28.12 Differences between simple one piece tunneled epidural catheter infusion and two pieces tunneled epidural catheter infusion.

Simple one piece tunneled epidural catheter infusion

Tunneled two pieces epidural catheter infusion

Position

Prone or lateral based on the patient comfort level

Same

Fluoroscopy

Preferred

Preferred

Needles used

Tuohy needle # 17 or 18 x 2; one used for epidural space access and

14 G, 7.6 cm Hustead

one for catheter tunneling

needle

Site of needle position

Variable based on the pain level

Same

Needle insertion

Paramedian approach is preferable but midline approach can be used

Same

Catheter used

Radio opaque catheter is preferred

Radio opaque (proximal)

catheter is included in the kit

space. Tunneled catheter is suitable for patients with cancer pain located anywhere from the neck to the lower extremities, and in patient with life expectancy of 3-6 months or less. Tunneled epidural catheter can be either simple epidural one piece catheter or tunneled epidural two-piece catheter with Dacron cuff and antibiotic cuff. The Dacron cuff is used to prevent slippage of the catheter out of the epidural space, and the antibiotic cuff is used to guard against infection. Infection is the most common complication of epidural catheter infusion. Table 28.12 describes the differences between the two types of epidural catheter. Figure 28.11a-f describes the implantation technique of a two-piece catheter.

Use and Maintenance Instructions (adopted with permission from Bard Access System manual)

General instructions:

• Postoperatively, the healthcare provider should observe incision sites for sepsis, inflammation, hematoma, seroma, and device erosion.

• Clamping is not necessary during either use or maintenance of the catheter. Toothed clamps, forceps, and scissors should not be used on or around the catheter.

• Routine catheter flushing is not required. If, however, the catheter is not used daily, it should be flushed once each week with 3 ml of sterile normal saline. Flush with saline (preservative free only), do not use any heparin-containing fluids.

Catheter dressing changes:

(1) Wash hands thoroughly with soap and water.

(2) Open dressing change supplies on a sterile field using sterile technique.

(3) Carefully remove the old dressing and wash hands again.

(4) Inspect catheter exit site closely for signs of infection or irritation.

(5) Clean any exudate from the exit site with hydrogen peroxide-soaked swaps.

(6) Using a povidone-iodine swab, apply gentle pressure and clean the exit site starting at the catheter and working outward in a circular motion. Never return to the catheter exit site with the same swab. Repeat the same procedure using two additional swabs.

Figure 28.11 Technique of implantation of two-piece catheter. (a) Setup of implantable two-piece catheter including VitaCuff® Antimicrobial Cuff, ventral incision (exit site), distal catheter segment, SureCuff® Tissue Ingrowth Cuff, proximal catheter segment, paravertebral incision, connector. (b) 1. Tunnel simultaneously from ventral exit site. 2. Advance catheter over barbed area tunneler. 3. Draw tunneler and catheter through subcutaneous tunnel to paravertibral incision. (c) Trim tubing, eliminate any acute angles or bends. Advance to middle of the connector using non-toothed forcep and rubber shods. Detail of technique for advancing catheter over connector. Rubber shods to protect catheter. (d) Bridge ties. (e) Positioning of VitaCuff® including exit site, VitaCuff® Antimicrobial Cuff, and SureCuff® Tissue Ingrowth Cuff. (f) Securing suture provides strain relief while awaiting tissue ingrowth into the SureCuff® Tissue Ingrowth Cuff (with permission from Bard Access Systems, Salt Lake City, UT).

Figure 28.11 Technique of implantation of two-piece catheter. (a) Setup of implantable two-piece catheter including VitaCuff® Antimicrobial Cuff, ventral incision (exit site), distal catheter segment, SureCuff® Tissue Ingrowth Cuff, proximal catheter segment, paravertebral incision, connector. (b) 1. Tunnel simultaneously from ventral exit site. 2. Advance catheter over barbed area tunneler. 3. Draw tunneler and catheter through subcutaneous tunnel to paravertibral incision. (c) Trim tubing, eliminate any acute angles or bends. Advance to middle of the connector using non-toothed forcep and rubber shods. Detail of technique for advancing catheter over connector. Rubber shods to protect catheter. (d) Bridge ties. (e) Positioning of VitaCuff® including exit site, VitaCuff® Antimicrobial Cuff, and SureCuff® Tissue Ingrowth Cuff. (f) Securing suture provides strain relief while awaiting tissue ingrowth into the SureCuff® Tissue Ingrowth Cuff (with permission from Bard Access Systems, Salt Lake City, UT).

Tunneled Epidural Catheter

(7) Using another povidone-iodine swab, clean a 2 in. (5 cm) length of catheter extending from the exit site outward. Apply povidone-iodine ointment to the exit site and extending 1 in. from the exit site outward along the catheter.

(8) Apply a transparent dressing or sterile gauze dressing over the catheter exit site.

(9) Coil the catheter and secure it over dressing with tape.

(10) Date the dressing on the tape and document dressing change on patient's chart.

(11) If evidence of infection or incomplete wound healing such as redness, swelling, induration, pain, or exudate over the wound or at exit site is present, change dressing daily. If the wound site is completely healed, change dressing less frequently or in accordance with hospital policy. Exit site should be cleaned daily, however.

Filter and cap change:

(1) Wash hands thoroughly with soap and water.

(2) Open package containing special Du Pen epidural catheter filter with pre-attached injection cap #0602920. Cleanse junction of catheter connector and filter with a povidone-iodine swab. Allow to air dry for 2 min.

(3) Grasping old filter and catheter connector in opposite hands, gently twist counterclockwise to remove used filter.

(4) Remove shield from Luer fitting of new filter and attach securely to indwelling catheter Luer adapter by clockwise rotation.

(5) The filter and cap should be replaced every 48 h and anytime the filter is removed from the catheter. If any leaking at the septum or Luer connections is observed, the filter should be discarded and replaced immediately. 20 G x 1 in. (2.5 cm) needles, or smaller, are recommended for puncturing the injection cap.

(6) If a continuous epidural infusion is used, change tubing and filter daily.

Administration of medications:

(1) Wash hands thoroughly with soap and water.

(2) Draw up correct amount of morphine sulfate. If using a multidose vial, wipe top with povidone-iodine. Remove excess with sterile 2 in. x 2 in. (5 cm x 5 cm) gauze before puncturing vial top with needle.

(3) Wipe top of vial containing preservative-free sodium chloride with povidone-iodine. Remove excess with sterile 2 in. x 2 in. (5 cm x 5 cm) gauze before puncturing vial top with needle.

(4) Inject narcotic into vial of preservative-free sodium chloride to achieve desired dilution volume and gently mix by rocking the vial.

(5) Wipe top of preservative-free sodium chloride vial again with povidone-iodine. Remove excess with sterile 2 in. x 2 in. (5 cm x 5 cm) gauze.

(6) Aspirate morphine sulfate solution into a 12 cc syringe through a 1 in. (2.5 cm) 20 G needle.

(7) Wipe injection cap attached to catheter filter with povidone-iodine. Allow to air dry for 2 min. Remove excess with sterile 2 in. x 2 in. (5 cm x 5 cm) gauze.

(8) Insert needle into injection cap and slowly inject the morphine sulfate (1 cc/min or at a rate that is tolerated by the patient) using firm pressure. It is not necessary to flush the catheter after administering the medication.

Was this article helpful?

0 0
10 Ways To Fight Off Cancer

10 Ways To Fight Off Cancer

Learning About 10 Ways Fight Off Cancer Can Have Amazing Benefits For Your Life The Best Tips On How To Keep This Killer At Bay Discovering that you or a loved one has cancer can be utterly terrifying. All the same, once you comprehend the causes of cancer and learn how to reverse those causes, you or your loved one may have more than a fighting chance of beating out cancer.

Get My Free Ebook


Post a comment