More on problems with removing the arrow FlexTip epidural catheter: smooth in-hardly out?

To the Editor:—We read with great interest the letter from Woehlck et al. and the accompanying response from Arrow Inc., (Reading, PA) concerning problems with removing the Arrow FlexTip epidural catheter. We wish to underline the importance of this topic with our own experience. In a woman (65 yr, American Society of Anesthesiologists physical status III, 167 cm, 72 kg) a thoracic epidural catheter (7/8 interspace, in place for 7 days) could not be removed despite multiple attempts, including replacing the patient in the position in which the catheter had been inserted. Unfortunately the plastic outer portion disrupted first and then the wire. After radiographic visualization, the remaining part of the disrupted catheter needed to be removed surgically. Both parts of the disrupted catheter were sent to Arrow Inc., for analysis, but no signs of failure of material could be detected. In a 48-yr-old man (American Society of Anesthesiologists physical status I, 187 cm, 83 kg) lumbar epidural anesthesia, with use of a FlexTip catheter for arthroscopic surgery of the knee, was induced with the patient in the right lateral decubitus position. After the operation, multiple attempts to remove the catheter while the patient was in the left lateral decubitus position were unsuccessful. Therefore, we turned the patient in the right lateral decubitus position, in which position the catheter originally had been inserted. During this maneuver, we observed that the catheter shifted around 2.5 cm within the skin across the back of the patient. After replacing the patient in the right lateral decubitus position the catheter could be removed without any problems. Thereafter, we were aware of at least two other patients in whom an epidural catheter could only be removed with considerable (in our experience, unusual) resistance in the sitting and semirecumbent positions, respectively, and we were unable to explain this phenomenon. Both catheters could be removed easily after replacing the patients in the lateral decubitus position, in which position the catheter originally had been inserted. We agree completely with Keim that (1) occasionally a FlexTip is more difficult to remove and requires extra care and (2) that, in the case of problems of removal of the FlexTip catheter, it might be removed successfully with the patient in the position in which it had been inserted originally. Therefore, we propose incorporation of both statements in the manufacturer guidelines for use.