Total spinal anaesthesia and respiratory arrest during patient transfer following unrecognised subdural catheter placement during labour.

Accidental subdural catheterisation is a complication of epidural analgesia with an incidence of 0.02-0.82%. 1 Lubenow T. Keh-Wong E. Kristof K. Ivankovich O. Ivankovich A.D. Inadvertent subdural injection: A complication of an epidural block. Anesth Analg. 1988; 67: 175-179 Google Scholar , 2 Jenkins J. Some immediate serious complications of obstetric epidural analgesia and anaesthesia: a prospective study of 145 550 epidurals. Int J Obstet Anesth. 2005; 14: 37-42https://doi.org/10.1016/j.ijoa.2004.07.009 Google Scholar The clinical presentation is usually heterogenous due to the anatomic variability of the dissection plane and the pattern of spread of local anaesthetic. 3 Hoftman NN, Ferrante FM. Diagnosis of unintentional subdural anesthesia/analgesia: analyzing radiographically proven cases to define the clinical entity and to develop a diagnostic algorithm. Reg Anesth Pain Med. 2009;34:12-16. https://doi.org/10.1097/AAP.0b013e31819339cf Google Scholar We report a case of total spinal anaesthesia following unrecognised subdural catheter placement during labour.