title: Partial displacement of epidural catheter after patient position change: A case report.
abstract: Epidural catheter migration is a well-known cause of failed anesthesia and complications. One of the factors that affect catheter movement is when patients change their position after skin fixation. We report a case of an epidural catheter placed without evidence of intravascular or subdural insertion that produced an insufficient block. A 36-year-old woman presented for ankle surgery under epidural anesthesia. Epidural block was conducted at the L3-4 intervertebral space with a catheter threaded 3 cm into the epidural space with the patient in a back flexion and lateral position. The total volume of injected anesthetic was 28 mL, including a 3-mL test dose. The final anesthesia level was L1. The planned operation was completed without a pneumatic tourniquet. A postoperative C-arm fluoroscopic image revealed that 1 side hole of the catheter had moved out of the epidural space. We think that a positional change after catheter fixation was the reason for catheter outmigration leading to insufficient analgesia, which was incompatible with the amount of local anesthetic injected.
authors.affiliation: Department of Anesthesiology and Pain Medicine, Kangwon National University Hospital, Kangwon National University School of Medicine, Chuncheon, Republic of Korea.
authors.forename: Yoon-Jung
authors.initials: YJ
authors.lastname: Shon
authors.affiliation: Department of Anesthesiology and Pain Medicine, Kangwon National University Hospital, Kangwon National University School of Medicine, Chuncheon, Republic of Korea.
authors.forename: Seung-Kil
authors.initials: SK
authors.lastname: Bae
authors.affiliation: Department of Anesthesiology and Pain Medicine, Kangwon National University Hospital, Kangwon National University School of Medicine, Chuncheon, Republic of Korea.
authors.forename: Jae-Woo
authors.initials: JW
authors.lastname: Park
authors.affiliation: Department of Anesthesiology and Pain Medicine, Kangwon National University Hospital, Kangwon National University School of Medicine, Chuncheon, Republic of Korea.
authors.forename: In-Nam
authors.initials: IN
authors.lastname: Kim
authors.affiliation: Department of Anesthesiology and Pain Medicine, Kangwon National University Hospital, Kangwon National University School of Medicine, Chuncheon, Republic of Korea. Electronic address: huhjin419@gmail.com.
authors.forename: Jin
authors.initials: J
authors.lastname: Huh
mesh_terms: D000328:Adult; D000767:Anesthesia, Epidural / Q000009:adverse effects*; D000779:Anesthetics, Local / Q000008:administration & dosage*; D064386:Ankle Fractures / Q000601:surgery; D002404:Catheterization / Q000009:adverse effects*; D003287:Contrast Media / Q000008:administration & dosage; D005260:Female; D005471:Fluoroscopy; D005593:Fracture Fixation, Internal / Q000009:adverse effects*; D006801:Humans; D007431:Intraoperative Complications / Q000000981:diagnostic imaging; D008159:Lumbar Vertebrae; D008160:Lumbosacral Plexus / Q000187:drug effects; D009068:Movement; D009407:Nerve Block / Q000009:adverse effects*; D016683:Supine Position
chemical_list: D000779:Anesthetics, Local; D003287:Contrast Media
keywords: Catheter displacement; Epidural block; Epidural catheter