Epidural catheter migration during cesarean

Background: Early detection and vigilance of high spinal anesthesia post epidural catheter migration in cesarean section leads to safe conduct of anesthesia. Our case describes the migration of a previously functioning epidural catheter in the subarachnoid space. This migration can be explained by patient posture changes and movements. Case presentation: A 32 year - old G2P0 medically free female parturient (height 160cm, weight 65 kg), admitted to the labor ward with a 4 cm cervical dilatation, an epidural catheter was inserted in the L3-4 space, and an aspiration test was negative for CSF/blood through epidural catheter. Epidural catheter was fixed on her back using sterile dressings. Epidural mixture of 0.1% bupivacaine and fentanyl 2 mcg/ml started. Due to fetal distress, cesarean section was urgently planned. She was given a bolus dose through the epidural catheter,10 minutes after skin incision, the patient suddenly started to complain of difficulty of breathing and drowsiness. Moreover, her oxygen saturation suddenly started to drop so rapid sequence induction with cricoid pressure applied and was performed till she was intubated. Her pupils were reactive and dilated. She had stable vital signs. She was reversed with neostigmine and atropine after the use of nerve stimulator. Aspiration from the epidural catheter was performed. A clear 10mls fluid was aspirated. The fluid was sent to the lab for analysis and found to be CSF. Upon extubation, the patient was conscious and obeying commands. She completely recovered the motor power of her upper and lower limbs while she was admitted to ICU for observation and she was discharged the next day without any residual anesthesia. Conclusion: Aspiration test and epinephrine test dose is always recommend to be performed prior to local epidural anesthetic for cesarean section even if the function of the epidural catheter was previously established. Careful observation of neurologic signs is also important.