Mystery of the missing epidural tip! Was it really missing?

Dear Editor, A broken epidural catheter is a rare complication that is known to occur in 0.002% of cases of epidural catheter insertion.[1] An elderly female underwent surgery for fracture neck of femur under combined spinal epidural technique in our institute. Under strict aseptic precautions, using a 16-G Touhy needle, epidural space was identified using the LOR technique, and the epidural catheter was advanced and fixed at 11 cm. Patency of the epidural catheter was confirmed, and top-ups were given at regular intervals till 48 h postoperatively, after which the epidural catheter was removed. However, it was noticed that the radiopaque colored tip was missing, creating an alarming situation. To ascertain the length of the missing fragment, the length of the tip from various marks on the epidural catheter was measured and found to be adequate. A new packing of the same brand was opened, and both the catheters were compared.[1] [Figure 1]. It was noticed that the catheters of this brand were manufactured without a colored tip. Obviously, the pre-use check was not done.Figure 1: Comparison of the two epidural catheters. (a) Epidural Catheter removed from patient (b) New epidural catheter from same manufacturerChecklists are the most common cognitive aids that enlist the set of actions that need to be performed in a given clinical procedure or scenario to ensure that none of the steps are omitted or forgotten as well as improve the quality of handovers without missing any vital information.[2] Lessons can be learned from the aviation industry’s “Crew Resource Management” wherein checklists are used at every step and followed. We solved the mystery of the missing epidural catheter, which was in fact, the missing pre-use check and the checklist. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.