Visible Evidence of Lumbar Epidural Catheter Misplacement–A Critical Incident Case Report

Abstract

A 57-year-old, male patient (165 cm, 66 kg) was scheduled to undergo right radical nephrectomy for renal cell carcinoma. Clinical history, physical examinations and laboratory investigations of the patient were normal. After placing the patient in right lateral position, epidural space was identified at first attempt with 18G Tuohy needle (BD Perisafe, Belgium) via a midline approach at L2-L3 intervertebral space using loss of resistance to air technique. A 20G multiorifice epidural catheter was threaded through the cranially directed tip of epidural needle to the 15 cm mark. The needle was removed and the catheter was left 6 cm into the epidural space. Patient did not complain of pain or paraesthesia during the procedure. Because of paucity of time both epidural test dose (3 ml of 2% lignocaine with 1:200000 epinephrine) and analgesia was given after induction of general anaesthesia. After pre-medication with fentanyl 100 μg intravenous (IV), the patient was given balanced general anaesthesia. Induction was performed with propofol 150 mg IV and atracurium 35 mg IV was given to facilitate endotracheal intubation and was maintained with isoflurane 0.2% -0.8% in an oxygen-nitrous oxide mixture at a 1:1 ratio. After induction, 0.25% bupivacaine 10 ml was given through epidural catheter without having any effect on haemodynamics. Surgery proceeded via right subcostal incision with the patient in the supine position. The right kidney was removed and near the end of surgery, when the surgeon was examining the renal bed, the distal portion of the epidural catheter was seen. The catheter was lying parallel to the inferior vena cava in front of psoas major muscle at the L1-L2 level [Table/ Fig-1]. Retrograde dissection revealed the catheter emerging from the anterior vertebral fascia at the L2-L3 level. Further confirmation was done by flushing the catheter with the normal saline which was coming out of the multiorifice at the distal end of the catheter. Catheter was removed and intravenous tramadol was used for postoperative pain management. DISCUSSIONCritical incident reporting is a valuable part of quality assurance. Identifying and mitigating risk factors associated with patient harm can improve patient safety [1]. Though various imaging studies and direct evidence case reports of epidural catheter misplacement in different regions of vertebral column have been reported, only one case of direct visible evidence of transforaminal escape of lumbar epidural catheter has been reported to our knowledge [2].Due to lack of uniform outcome measures, incidence of failure of epidural anaesthesia and analgesia ranges from 13% to as high as 47% [3]. Factors that influence the technical failure of epidural anaesthesia and analgesia are, anatomical catheter location, patient position, puncture site, midline versus paramedian approach, methods to localize epidural space, catheter insertion and fixation and equipment related problems.Three cases of misplaced epidural catheter into the thoracic cavity found during surgery have been r...

Epidural Catheter Migration: A Case Report of a CT Scan Examination

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