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Case Report

Korean J Pain 2011; 24(1): 44-47

Published online March 31, 2011 https://doi.org/10.3344/kjp.2011.24.1.44

Copyright © The Korean Pain Society.

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

Se Jin Lee, MD, Sang Ho Kim, MD*, Sun Young Park, MD, Mun Gyu Kim, MD, Bo Il Jung, MD, and Si Young Ok, MD

Department of Anesthesiology and Pain Medicine, College of Medicine, Soonchunhyang University, Seoul, Korea.

Correspondence to: Sang Ho Kim, MD. Department of Anesthesiology and Pain Medicine, College of Medicine, Soonchunhyang University, 22, Daesagwan-gil, Yongsan-gu, Seoul 140-743, Korea. Tel: +82-2-709-9114, Fax: +82-2-790-0394, pc@schmc.ac.kr

Received: January 20, 2011; Revised: January 27, 2011; Accepted: January 27, 2011

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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.

Keywords: catheter malposition, epidural anesthesia, epidural space