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Peer-reviewedCC BYJA clinical reports

Early recognition and safe management of unintentional intrathecal placement of an epidural catheter during combined spinal-epidural labor analgesia: a case report in the context of the 2024 OAA guidelines.

  • Hidenobu Watanabe1,2
  • Choko Kume3
  • Arisa Ijuin3
  • Yoko Yamashita3
  • Masaki Sato3
  • Reiko Ohara3
  1. 1Department of Anesthesiology, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-Ku, Tokyo, 157-8535, Japan. [email protected].
  2. 2Department of Anesthesiology, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-8611, Japan. [email protected].
  3. 3Department of Anesthesiology, National Center for Child Health and Development, 2-10-1 Okura, Setagaya-Ku, Tokyo, 157-8535, Japan.
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Abstract

Background

Unintentional intrathecal catheter placement is a recognized complication of labor neuraxial analgesia. Although continuous spinal analgesia (CSA) may be used as a management option, prompt recognition, careful catheter management, and close monitoring are required to prevent complications such as severe spinal anesthesia.Case presentation

A 31-year-old primigravida underwent combined spinal-epidural analgesia for labor pain. Intrathecal catheter placement was diagnosed after a test dose was administered based on hypotension, motor weakness, sensory block, and glucose-positive aspirated fluid. The catheter was managed as CSA with fentanyl-based analgesia under strict monitoring. Although frequent breakthrough pain required rescue boluses, the vaginal delivery was achieved uneventfully. The patient developed a post-dural puncture headache that resolved after an epidural blood patch.Conclusions

This case illustrates the importance of early recognition of inadvertent intrathecal catheter placement and demonstrates that safe labor analgesia can be achieved through conversion to CSA with careful catheter management and close monitoring.

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Cite

BibTeXRIS
BibTeX
@article{watanabe2026early,
  title = {{Early recognition and safe management of unintentional intrathecal placement of an epidural catheter during combined spinal-epidural labor analgesia: a case report in the context of the 2024 OAA guidelines.}},
  author = {Hidenobu Watanabe and Choko Kume and Arisa Ijuin and Yoko Yamashita and Masaki Sato and Reiko Ohara},
  journal = {JA clinical reports},
  year = {2026},
  month = jul,
  doi = {10.1186/s40981-026-00869-1},
  url = {https://europepmc.org/article/MED/42894088},
  note = {CC BY},
}
RIS
TY  - JOUR
TI  - Early recognition and safe management of unintentional intrathecal placement of an epidural catheter during combined spinal-epidural labor analgesia: a case report in the context of the 2024 OAA guidelines.
AU  - Hidenobu Watanabe
AU  - Choko Kume
AU  - Arisa Ijuin
AU  - Yoko Yamashita
AU  - Masaki Sato
AU  - Reiko Ohara
PY  - 2026
DA  - 2026/07/01
JO  - JA clinical reports
DO  - 10.1186/s40981-026-00869-1
UR  - https://europepmc.org/article/MED/42894088
AB  - Background  Unintentional intrathecal catheter placement is a recognized complication of labor neuraxial analgesia. Although continuous spinal analgesia (CSA) may be used as a management option, prompt recognition, careful catheter management, and close monitoring are required to prevent complications such as severe spinal anesthesia.Case presentation  A 31-year-old primigravida underwent combined spinal-epidural analgesia for labor pain. Intrathecal catheter placement was diagnosed after a test dose was administered based on hypotension, motor weakness, sensory block, and glucose-positive aspirated fluid. The catheter was managed as CSA with fentanyl-based analgesia under strict monitoring. Although frequent breakthrough pain required rescue boluses, the vaginal delivery was achieved uneventfully. The patient developed a post-dural puncture headache that resolved after an epidural blood patch.Conclusions  This case illustrates the importance of early recognition of inadvertent intrathecal catheter placement and demonstrates that safe labor analgesia can be achieved through conversion to CSA with careful catheter management and close monitoring.
SN  - 2363-9024
ER  -