title: Case report: inadvertent intrathecal placement of a pulmonary artery catheter introducer.
abstract: We present a case of unintended intrathecal cannulation by a pulmonary artery catheter introducer in a patient scheduled for coronary surgery. This complication was likely due to multiple attempts of placing the guidewire. Switching to the straight tip of the guidewire may have created a false route, facilitating entrance in the subarachnoid space. A lumbar intrathecal catheter was placed to maintain a low pressure at the cervical dural puncture site by draining 10 mL cerebrospinal fluid per hour. After removal of the lumbar drain, the patient experienced symptoms consistent with postdural puncture headache. Magnetic resonance imaging of the spine could not reveal the location of the possible leak. A lumbar epidural blood patch alleviated all complaints. One month later the patient underwent surgery successfully. We hypothesize that ultrasound imaging may have prevented this complication.
authors.affiliation: Department of Anesthesiology, University Hospital Antwerp, Wilrijkstraat 10, B-2650 Edegem, Belgium. marcel.vercauteren@uza.be
authors.forename: Marcel
authors.initials: M
authors.lastname: Schepers
authors.forename: Marcel
authors.initials: M
authors.lastname: Vercauteren
authors.forename: Dina
authors.initials: D
authors.lastname: De Bock
authors.forename: Inez
authors.initials: I
authors.lastname: Rodrigus
authors.forename: David
authors.initials: D
authors.lastname: Vanderplanken
authors.forename: Michael
authors.initials: M
authors.lastname: Camerlinck
mesh_terms: D000368:Aged; D002405:Catheterization, Central Venous / Q000009:adverse effects* / Q000295:instrumentation; D006801:Humans; D007431:Intraoperative Complications / Q000000981:diagnostic imaging* / Q000209:etiology; D008297:Male; D051299:Post-Dural Puncture Headache / Q000000981:diagnostic imaging* / Q000209:etiology; D011651:Pulmonary Artery / Q000000981:diagnostic imaging*; D011859:Radiography