Removing epidural catheters:

A guide for nurses

BY MONAKSHI SAWHNEY, PhD, MN, BScN, NP; SHERIDA CHAMBERS, MSN, BSN, RN; AND FELIKS HYSI, MN, BSN, BS, RN

Abstract: Short-term epidural analgesia is effective for postoperative pain, procedural pain,
trauma pain, and labor pain. This article describes the skills, procedures, and nursing care
required for removing a short-term, temporary epidural catheter.

Keywords: Epidural analgesia, epidural catheters, epidural space, spinal epidural hematoma

ANALGESIA DELIVERED by focus of this article is on short-term,

an epidural catheter refers to the
administration of opioids and/or local
anesthetics into the epidural space by
a single or intermittent bolus injec-
tion, continuous infusion, or patient-
controlled epidural analgesia with
or without continuous infusion (see
Anatomy of the epidural space).1
Short-term epidural analgesia is
administered through a temporary
catheter and external infusion de-
vice. Long-term administration is
ERAXION / THINKSTOCK
temporary epidural catheters.
Indications for short-term epidural
analgesia include the management of
postoperative pain, procedural pain,
trauma pain, and labor pain.2,3
Short-term epidural catheters may be
left in place from a few hours to up
to 5 days.2
In patients receiving epidural anal-
gesia, nursing interventions include
administration of local anesthetics
and/or opioids through the epidural

provided by either a tunneled cath- catheter and assessment of the

eter and external infusion device or following:2
an implanted catheter and implant- • vital signs
ed refillable infusion device.2 The • pain

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• sedation level in your facility. This article de- coagulation, which may be pre-
• sensory and motor function scribes the required skills and scribed to reduce the risks of venous
• adverse reactions procedure for catheter removal and thromboembolism. If this is the case,
• signs and symptoms of complica- the corresponding nursing care. note the drug, dosage, and time of
tions, such as nerve injury the last dose. For management
• insertion site and dressing Requirements before guidelines regarding care for patients
• catheter, tubing connections, and you start receiving both epidural analgesia and
the infusion device. Begin by assessing and managing the anticoagulation, follow the facility’s
Nurses may also be permitted patient’s pain, and make sure alter- policies and procedures or the pre-
to remove epidural catheters. It is native analgesia is available once scriber’s orders for how long anti-
important to ensure this skill is epidural analgesia is discontinued. coagulation must be held before
supported by your regulatory An important step is to determine catheter removal. The guidelines
body and the appropriate policy whether the patient is receiving anti- from the American Society of Re-
gional Anesthesia and Pain Medicine
Anatomy of the epidural space1 regarding the management of pa-
tients who are concurrently receiving
The epidural space is the area between the dura mater and the vertebral wall. The
epidural analgesia and anticoagula-
dura is adherent to the bone above the foramen magnum. In contrast, an actual or
true epidural space exists below the foramen magnum posterior and lateral to the
tion is also a good resource.4
spinal cord that extends down the length of the spinal canal. This space is small in Review the patient’s coagulation
the cervical region and larger in the sacral region. The epidural space contains fat panel results; it is preferred that these
as well as arteries and a venous plexus. be obtained and reported within 24
hours of a scheduled catheter removal.
A
If the lab values are abnormal, do not
Vertebral
body
remove the epidural catheter. Instead,
Spinal cord
notify the provider responsible for
Nerve roots
managing the epidural catheter, which
Dura

Ligamentum
is typically the anesthesiologist.5
flavum

Epidural
space Catheter removal
• Position the patient lying down in a
lateral position with the head and
shoulders flexed toward the chest, or
sitting on the edge of the bed with the
head and back flexed forward.6
• Turn off the epidural infusion, if
B
applicable.
Spinal nerves
Dura
Spinal cord
Dura
Spinal cord
• Perform hand hygiene and apply
Ligamentum flavum Ligamentum
flavum
clean gloves and any other appropri-
Epidural
space
ate personal protective equipment.
• Carefully remove the tape or other
device that is securing the epidural
catheter to the skin and remove the
dressing.
• Grasp the epidural catheter at the
insertion site and gently, slowly, and
The epidural space is the outermost steadily withdraw it at a 90-degree
space in the spinal canal, lying
angle to the skin surface.6,7
outside the dura mater inside the
If you encounter resistance, do
surrounding vertebrae. A. Axial view
of the epidural space. B. sagittal view
not apply more force, as this may
of the epidural space. damage or break the catheter. Instead,
reposition the patient by increasing
Source: Hoppenfeld JD. Fundamentals of Pain Medicine: How to Diagnose and Treat Your Patients. flexion and reattempt removal. It is
Philadelphia, PA: Wolters Kluwer Health; 2014.
also recommended to place patients

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Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

in the same position as they were at
the time of insertion.8
If you encounter too much resis-
tance or the patient experiences any
unusual symptoms such as pain or
numbness, stop the removal attempt,
cover the free end of the catheter and
the insertion site with sterile gauze,
and notify the responsible provider.
• After a successful catheter removal,
immediately examine the tip of the
catheter to ensure it is intact. The tip
should have a solid, dark-colored
marking.
• Assess the catheter insertion site for
signs and symptoms of bleeding, hema-
toma, or infection, including erythema,
exudate, and pain or tenderness.9
• Clean the site as per facility policies
and procedures, and apply a sterile
adhesive dressing, which can usually
be removed within 24 hours.
• Document the date and time of cath-
eter removal, the condition of the cath-
eter tip, the presence of any drainage
or bleeding at the insertion site, the
patient’s response to the procedure,
and any difficulty with removal. Also
document whether you had to notify
the prescriber and any other prescribed
interventions that were performed.
Potential complications
Complications that can occur during
epidural catheter removal include
breakage, entrapment, knotting, and
disruption.3 For example, excessive
force or tension during removal may
result in catheter sheering or break-
age.10 In the event of breakage,
asymptomatic patients are managed
with imaging and follow-up regarding
potential complications; symptomatic
patients require surgical removal
of the catheter.11
Other complications include he-
matoma and infection.5,9,12-14 Spinal
epidural hematoma (SEH) is a seri-
ous complication, with an estimated
incidence ranging from 0 to 2.25 per
10,000 epidurals.13-15 Signs and
symptoms include a progressive loss
of sensation or motor function in the
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lower extremities, bowel and/or
bladder dysfunction, and back
pain.5,9,13 Bowel and/or bladder dys-
function is a late sign of SEH.11 If
SEH is suspected, urgent MRI or
computed tomography is required; if
SEH is detected, urgent surgical re-
moval is required.5
Site infection is another potentially
serious complication. Early signs and
symptoms of epidural site infection
include back pain, fever, headache,
and erythema.9 Later signs include
stiff neck, radiating pain, photopho-
bia, loss of motor function, and con-
fusion. Management of infection in-
cludes consultation with a neurologist
and/or an infectious disease special-
ist.9
Ongoing care
After catheter removal, continue to
assess for signs and symptoms of
possible complications such as SEH
or infection. Instruct patients to re-
port any new symptoms such as
lower extremity weakness, paresthe-
sia, or back pain immediately.5,9,12
Monitor the patient for adverse
drug reactions related to epidural
medication. If the patient received an
opioid, monitor for sedation and re-
spiratory depression.1,2 If the patient
was administered a local anesthetic,
monitor for local anesthetic toxicity for
up to 6 hours after catheter removal.16
Short-term epidural analgesia is
commonly used in pain manage-
ment, and nurses must be prepared
to manage catheters as required.
This includes assessing and provid-
ing care to patients during epidural
infusion. It may also include the safe
removal of epidural catheters and
post-removal monitoring. ■
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Monakshi Sawhney is an assistant professor at Queen’s
University in Kingston, ON, Canada. Sherida Chambers
is a clinical manager at Humber River Hospital in To-
ronto, ON. Feliks Hysi is a clinical educator at Joseph
Brant Hospital in Burlington, ON.
The authors have disclosed no financial relationships
related to this article.
DOI-10.1097/01.NURSE.0000546459.86617.2a
December l Nursing2018 l 49