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Background and Aims Unrecognized spinal placement of an epidural catheter is a serious complication. It can cause a high/total spinal block which can lead to a catastrophic outcome.
Results A 37 year old woman was admitted to elective cesarian section at 39 weeks of gestation. Previous history includes an uneventful cesarian section 7 years ago. A combined spinal-epidural block in the sitting position through the L3/L4 intervertebral space using a median approach was achieved after 3 attempts by loss of resistance to normal saline. A needle-through-needle technique was performed. CSF flow was confirmed by glucose testing and 1.6ml 0,5% Bupivacaine and 2 µg sufentanyl were administered. The epidural catheter was then inserted and negative aspiration was confirmed. Due to incomplete block for surgery, 9.5mL of 2% lidocaine was injected through the epidural catheter after negative aspiration. During the following minutes, the patient gradually complained a feeling of imminent death and upper limb paresthesia, and rapidly progressed to apnea. A rapid sequence induction was immediately performed, with mechanical ventilation. A double check of the epidural catheter uncovered a positive aspiration of LCR. The cesarian section was uneventful and the patient was extubated at the end of surgery, forty minutes later. No other complications developed. She remained stable and after 4 hours both motor and sensitive blocks were fully reversed.
Conclusions The most likely mechanism responsible for the high spinal block was the migration of the epidural catheter while the patient was repositioned, perhaps through the dural puncture caused by the spinal needle.
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