Intrapleural misplacement of a thoracic epidural catheter in an anesthetized patient

Thoracic epidural analgesia provides adequate postoperative pain relief and favorable outcomes in major operations. However, a small number of devastating complications have been reported. Here we present a case of asymptomatic but potentially life-threatening intrapleural insertion of a thoracic epidural catheter intended for postoperative analgesia. A 39-year-old male diagnosed with esophageal carcinoma was scheduled for esophageal reconstruction. After induction of general anesthesia, a thoracic epidural catheter was inserted with a paramedian approach at the T8-9 interspace, using loss of resistance to ensure correct placement. The administration of a test dose of 2% lidocaine with epinephrine was unremarkable. After right thoracotomy, the epidural catheter was found in the right pleural cavity and was instantly removed. The patient underwent the operation smoothly and was discharged 10 days later without any sequelae. We recommend practitioners estimate the depth from the skin to the epidural space by computed tomography scan before operation and perform the placement of thoracic epidural catheter while the patient is awake to avoid accidental intrapleural misplacement.