MalfunctionOGE
PERIFIX
Received Oct 21, 2024 · Event occurred Oct 3, 2024
Report MW5161280 · MDR key 20506167
Device
Generic name
Epidural Anesthesia Kit
Manufacturer
B. Braun Medical Inc.Model number
332097Lot number
0061944517
Patient
76 YR · Male
- No Clinical Signs, Symptoms or Conditions
- No Clinical Signs, Symptoms or Conditions
Narrative
Description of Event or Problem
DURING THE PLACEMENT OF THE EPIDURAL CATHETER RESISTANCE WAS MET, AND THE CATHETER COULD NOT BE THREADED ANY FURTHER. A DECISION WAS MADE TO REMOVE THE CATHETER HOWEVER IT FELT STUCK. THE WHOLE EPIDURAL NEEDLE WAS REMOVED BUT THERE WAS RESISTANCE TO REMOVING THE REST OF THE CATHETER. THE TIP OF THE CATHETER COULD NOT BE VISUALIZED INDICATING THERE WAS HIGH PROBABILITY OF A RETAINED EPIDURAL CATHETER IN THE LUMBAR AREA. AN MRI CONFIRMED CATHETER WAS RETAINED IN THE EPIDURAL SPACE. AN INSPECTION OF THE CATHETER SHOWED IT WAS SHREDDED.