Neuraxial anesthesia is commonly used to administer medication into the subarachnoid or epidural space. Inadvertent intravascular injection of a local anesthetic during neuraxial anesthesia has several consequences, including circumoral numbness, facial tingling, metallic taste in the mouth, and potentially local anesthetic systemic toxicity, which can lead to cardiovascular collapse. In this report, we present a case of a patient suspected of having an intravascular epidural catheter with an epidural catheter placement despite repeated negative aspiration tests.

26 year old female, G1P0, PMH of severe anxiety, preeclampsia, and gestational DM. Epidural requested and placed, using a Tuohy needle and a loss of resistance technique with air. An aspiration test was performed, using a 3cc needle positioned below the catheter insertion site, with negative CSF or blood. A pharmacologic test dose was administered (3cc of 1% lidocaine with 1:200,000 epi), and shortly after, our patient became tachycardic with a heart rate (HR) of 130 beats per minute (baseline of 90), and hypertensive with a systolic blood pressure (SBP) of 170 (baseline of 140). She denied any ringing in her ears or a metallic taste in her mouth. The aspiration test was repeated and was negative. A repeat test dose with epinephrine was then administered, with a positive response. Our differential at this time included anxiety and an intravascular catheter, and so the epidural catheter was capped. Fifteen minutes later, we administered a placebo test dose of 3cc of normal saline, which was negative. Given the negative response to the placebo, we suspected an intravascular catheter. Treatment options were discussed. Our patient would not tolerate replacement of the epidural catheter. A decision was made to pull the epidural catheter 2cm. Aspiration with a 3cc needle was negative. Two test doses with epinephrine were administered, with negative symptoms. Shortly afterwards, our patient reported feeling numbness in her legs bilaterally. At this time, we were convinced the catheter was in the epidural space. She reported feeling significant pain relief from the epidural catheter until delivery via c-section conversion 12 hours later. Prior to the c-section, her epidural was tested with the aspiration technique and an epinephrine test dose, with negative symptoms.