A case of secondary subarachnoidal dislocation of a lumbar epidural catheter is reported. A 76 year-old female underwent resection of the sigmoid colon. In order to provide postoperative analgesia, an epidural catheter was inserted between the 3rd and 4th lumbar interspaces prior to induction of anaesthesia. Aspiration tests were negative twice and a test dose of 4 ml 0.5% bupivacaine produced no signs of anaesthesia. Thereafter, the operation was performed under balanced general anaesthesia. Prior to the end of surgery a total of 14 ml bupivacaine 0.5% was administered without significant cardiovascular depression. At the time of extubation the patient was awake and-free of pain. There was no sign of respiratory depression or paralysis of the upper extremities. Three hours later in the recovery room the patient complained of pain. After a negative aspiration test 14 ml bupivacaine 0.25% was injected. Thirty minutes after injection apnea and cardiac arrest occurred. Resuscitation was immediately started, resulting in quick restoration of circulation and restitutio ad integrum. Aspiration at this time showed cerebrospinal fluid. The latency of the onset of total spinal anaesthesia and the rapid restoration of stable vital functions, was astonishing. It is essential to observe the common precautions such as an aspiration test without a filter, administration of a test dose, and titration of the injected amount each time the anaesthetic agent is applied via an epidural catheter.
