Copyright © 2018 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited. XXX 2018 • Volume XXX • Number XXX www.anesthesia-analgesia.org 1 DOI: 10.1213/ANE.0000000000003311 T horacic epidural anesthesia via the caudal approach is used routinely in children to provide safe, effec- tive analgesia. 1,2 Radiographic confrmation is impor- tant to verify optimal catheter tip placement. 3 However, epidural catheters can still migrate after successful place- ment, fxation, and positioning. 4,5 Potential complications include dural puncture with inadvertent intrathecal block, intravascular migration with local anesthetic toxicity, or bradycardia if cephalad migration causes a high thoracic neuraxial block. 6,7 A recent study of thoracic epidurals in children described signifcant catheter migration. 8 A group in Italy reported no inward migration of thoracic epidural catheters when using Mastisol (Ferndale Laboratories, Ferndale, MI) and Tegaderm (3M, St Paul, MN). 9 However, both studies reported epidurals that were inserted at the thoracic level; to our knowledge, there are no studies of catheter migration in children with caudally threaded thoracic epidural catheters. Thus, we aimed to describe catheter migration in patients who received cau- dally threaded thoracic epidural catheters at our hospital during a 26-month period. METHODS Study Design and Cohort Selection Institutional review board approval was obtained before conducting this study. The requirement for written informed consent was waived by the institutional review board. The manuscript adheres to the applicable STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) guidelines. At our institution, radio-opaque Arrow (Telefex Medical, Kenosha, WI) catheters are threaded via the caudal route with the patient in the prone position. Each catheter tip location is confrmed via fuoroscopy or epidurogram, and then the catheter is secured with Dermabond (Ethicon, Summerville, KEY POINTS • Question: How often and how far do caudally threaded epidural catheters migrate in neonates and infants despite fxation with cyanoacrylate adhesive and waterproof dressing? • Findings: Fifty-four of 85 infants with caudally threaded thoracic epidural catheters demon- strated epidural catheter tip migration of 1 or more vertebral levels, and migration of 2 or more levels occurred only in children who weighed <6 kg. • Meaning: Epidural catheter migration occurs commonly in neonates and infants despite ad- hesive fxation, and the migration as measured by vertebral levels is greatest in the smallest infants. BACKGROUND: The migration of pediatric thoracic epidural catheters via a thoracic insertion site has been described. We assessed the migration of caudally threaded thoracic epidural catheters in neonates and infants at our institution. METHODS: The anesthesia records and diagnostic imaging studies of neonates and infants who had caudal epidural catheters placed during a 26-month period at our hospital were ana- lyzed. Imaging studies were reviewed for changes in epidural catheter tip position. RESULTS: Eighty-fve patients 1–325 days of age (median, 51 days; interquartile range, 39–78 days) and weights of 2.5–9.5 kg (median, 5 kg; interquartile range, 4.3–5.8 kg) met the study criteria. Fifty-four (64%) of the patients (95% CI, 52%–73%) experienced catheter migration of 1 or more vertebral levels (range, 3 levels caudad [outward] to 3 levels cephalad [inward]), and 23 (27%) of the patients (95% CI, 18%–38%) experienced catheter migration to the T4 level or higher. Migration of 2 or more vertebral levels occurred only in children who weighed <6 kg and were under 73 days of age. CONCLUSIONS: Epidural catheter migration occurs commonly in neonates and infants. Postoperative imaging is crucial to confrm catheter tip location after epidural catheter place- ment, as failure to assess catheter migration might result in suboptimal analgesia or other undesirable outcomes. (Anesth Analg XXX;XXX:00–00) The Migration of Caudally Threaded Thoracic Epidural Catheters in Neonates and Infants Allan F. Simpao, MD, MBI,* Jorge A. Gálvez, MD, MBI,* Elicia C. Wartman, BA,† W. Randall England, BA,† Lezhou Wu, PhD,† Mohamed A. Rehman, MD,‡ and Thienkim V. Ngo, MD§ From the *Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; †Department of Anesthesiology and Critical Care Medicine, General Anesthesia Division, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; ‡Department of Anesthesiology, Johns Hopkins All Children’s Hospital, St Petersburg, Florida; and §Department of Anesthesiology, Anesthesia Service Medical Group, Inc, Rady Children’s Hospital San Diego, San Diego, California. Accepted for publication December 22, 2018. Funding: Departmental. The authors declare no conficts of interest. Reprints will not be available from the authors. Address correspondence to Allan F. Simpao, MD, MBI, Department of An- esthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, The Children’s Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104. Address e-mail to simpaoa@email.chop.edu. Copyright © 2018 International Anesthesia Research Society