title: Inadvertent extra-epidural catheter placement in an infant.
abstract: We report the inadvertent passage of an epidural catheter threaded from the caudal space out of a lumbar intervertebral foramen and into the lower thoracic paravertebral space in an infant. We identified the errant catheter by radiography and removed it without sequelae.
authors.affiliation: *Department of Anesthesia, Hospital of the University of Pennsylvania; and Departments of †Anesthesiology and Critical Care Medicine and ‡Radiology, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania.
authors.forename: Darryl
authors.initials: D
authors.lastname: Berkowitz
authors.forename: Robin D
authors.initials: RD
authors.lastname: Kaye
authors.forename: Scott D
authors.initials: SD
authors.lastname: Markowitz
authors.forename: Scott D
authors.initials: SD
authors.lastname: Cook-Sather
mesh_terms: D000767:Anesthesia, Epidural / Q000009:adverse effects*; D002404:Catheterization / Q000009:adverse effects*; D015615:Cystic Adenomatoid Malformation of Lung, Congenital / Q000601:surgery; D004824:Epidural Space / Q000293:injuries*; D006801:Humans; D007223:Infant; D008297:Male; D019300:Medical Errors; D016343:Monitoring, Intraoperative; D013902:Radiography, Thoracic