RESUMO
BACKGROUND: Epidural catheters are routinely placed for many surgical procedures and to treat various pain conditions. Known complications arising from epidural catheter equipment malfunction include epidural pump failure, epidural catheter shearing, epidural catheter connector failure, epidural filter connector cracking, and loss-of-resistance syringe malfunction. Practitioners need to be aware of these potentially dangerous complications and take measures to mitigate the chances of causing significant patient harm. We report on the complete breakage of an epidural filter connector during epidural bolus administration of local anesthetic by hand with a syringe. CASE PRESENTATION: A B. Braun Perifix® epidural catheter was placed in a 73-year-old male scheduled for radical prostatectomy. During the operation, a continuous infusion of local anesthetic was administered through the epidural catheter in addition to general endotracheal anesthesia. At the conclusion of surgery and after extubation, the patient endorsed incisional pain. The epidural filter connector broke in half as a bolus of local anesthetic was administered by hand with a syringe. The local anesthetic sprayed widely throughout the room as the fragmented epidural filter connector became a projectile object that recoiled and struck the patient. CONCLUSIONS: This incident placed the patient and surrounding healthcare providers at substantial risk for injury and infection from the fractured epidural filter connector becoming a projectile object and from the local anesthetic spray. The most plausible cause of this event was from a large amount of pressure being applied to the filter connector. This may have occurred by excessive force being applied by hand to the syringe, by the presence of a clogged filter, or by the catheter being kinked or blocked proximal to the filter. Being aware of this deleterious complication and potentially modifying existing epidural bolus techniques, such as using smaller syringes with less applied force and checking all epidural components vigilantly prior to and during bolus administration, can help anesthesia providers deliver the safest possible care to patients with epidural catheters.