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JAMA Performance Improvement
March 28, 2017

Retained Lumbar Catheter Tip

Author Affiliations
  • 1Surgical Outcomes and Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University and Northwestern Memorial Hospital, Chicago, Illinois
  • 2Division of Quality, Northwestern Memorial Hospital, Chicago, Illinois

Copyright 2017 American Medical Association. All Rights Reserved.

JAMA. 2017;317(12):1269-1270. doi:10.1001/jama.2017.1713

A man underwent placement of a lumbar catheter to drain cerebrospinal fluid at the start of a vascular surgery procedure. On the first postoperative day, an anesthesia resident who had never removed this type of drain removed the drain after consulting with his attending physician. The patient was seen on postoperative day 6 in the vascular surgery clinic reporting drainage from the lumbar drain site that had persisted since hospital discharge. That same day, the anesthesia resident removed another lumbar catheter and noted that the tip appeared different than the previous one. Suspecting that a fragment of the catheter tip may have been retained in the patient, he notified the attending anesthesiologist and the vascular surgery clinic. On examination of the patient’s back, there was a raised area of skin with clear fluid at the lumbar drain site. Imaging was obtained, which confirmed the retained lumbar catheter tip.