Korean J Pain.  2011 Mar;24(1):44-47. 10.3344/kjp.2011.24.1.44.

Epidural Catheter Malposition in a Failed Epidural Anesthesia Confirmed by Computed Tomography

• Lee SJ
• Kim SH
• Park SY
• Kim MG
• Jung BI
• Ok SY

• KMID: 2278096
• DOI: http://doi.org/10.3344/kjp.2011.24.1.44

Abstract

We report a case of failed epidural anesthesia despite successful identification of the epidural space, loss of resistance technique, hanging drop method and drip infusion. This case evaluated the use of computed tomography to confirm epidural catheter position, which showed the catheter accidentally positioned at the T2 lamina. Because epidural anesthesia can even after successful procedure using standardized techniques such as loss of resistance, we recommend performing the procedure under fluoroscopic guidance to improve success rate and patient safety.

Keyword

catheter malposition; epidural anesthesia; epidural space

MeSH Terms

Anesthesia, Epidural
Catheters
Epidural Space
Infusions, Intravenous
Patient Safety

Figure

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  Fig. 1 Sitting position with the neck flexed and arms crossed for thoracic epidural puncture.

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  Fig. 2 Hemodialysis catheter insertion state and median sternotomy state due to CABG. Thin catheter is located in T1-2 intervertebral space, with contrast materials injected in soft tissue failing to demonstrate typical epidurogam.

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  Fig. 3 Epidural catheter inserted between T1 and T2 spinous process in the spine CT axial (A, B), sagittal (C) and 3D (D-F) views. Instead of crossing ligamentum flavum, epidural catheter navigated T2 right vertebral lamina and turned to the erector spinae muscle.

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