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PEDIATRIC ANESTHESIA

Inadvertent Extra-Epidural Catheter Placement in an Infant

Darryl Berkowitz, MD^*, Robin D. Kaye, MD, Scott D. Markowitz, MD^*, and Scott D. Cook-Sather, MD^*

*Department of Anesthesia, Hospital of the University of Pennsylvania; and Departments of Anesthesiology and Critical Care Medicine and Radiology, The Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania

We report the inadvertent passage of an epidural catheter threaded from the caudal space out of a lumbar intervertebral foramen and into the lower thoracic paravertebral space in an infant. We identified the errant catheter by radiography and removed it without sequelae.