[Migration of an axillary plexus catheter fragment : A severed catheter tip unnoticed on removal wandered into the central nervous system].

MIGRATION OF AN AXILLARY PLEXUS CATHETER FRAGMENT INTO THE INTRACEREBRAL COMPARTMENT

During removal of an axillary plexus catheter used for pain therapy, the catheter was probably inadvertently and unnoticed severed together with the suture fixation. The error went unnoticed and an approximately 14 cm long catheter fragment remained in the patient. The patient complained of neck pain, nausea and vomiting 2.5 years later. A computed tomography scan of the cranium and neck region revealed a tubular foreign body with a diameter of ca. 1 mm and a length of ca. 14 cm. The foreign body was identified to be the sheared catheter fragment. In the meantime, the fragment had obviously migrated from the axilla into the intracranial compartment. The tip of the catheter was found at the ventral surface of the pons and surgical extraction was not possible. Following a futile intervention by the hospital's liability insurance and despite evidence from an expert opinion for a gross treatment error, the patient took civil legal action against the hospital. A settlement was reached and the accused hospital committed itself to pay a compensation of 200,000 € plus any additional costs.