Epidural Catheter Migration in a Patient with Severe Spinal
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Abstract :
Establishment of appropriate neuraxial catheter positioning is typically a straightforward procedural undertaking. It can, however, lead to deception of even the most experienced clinician and occur despite the most meticulous attention to detail. Written and verbal consent were obtained from the patient to prepare, discuss, and publish this case report; we describe the occurrence of what we believe was the intraoperative migration of an epidural catheter in the setting of significant tissue changes resulting from a previous spinal fusion.

Case Report :
An elective right proximal femur replacement was scheduled for a 70-year-old, 79?kg female. The patient had a past medical history which included severe lumbar stenosis, previous lumber spine fusion from L3 to L5, severe arthritis, coronary artery disease, scleroderma, asthma, and pulmonary hypertension. A lumbar epidural was placed at the T12-L1 level in the operating suite after two attempts and prior to the induction of general anesthesia. A closed tip, multiorifice catheter was used........

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5206424/
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