Inadvertent epidural administration of potassium chloride

Tessler, Michael J.; White, I. W. C.; Naugler-Colville, MaryAnne; Biehl, Diane R.

doi:10.1007/bf03020353

Cited by 41 publications

(5 citation statements)

References 8 publications

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“…Similarly, a sudden 'flick' of the catheter tip during injection would be unlikely to cause such severe pain of such a long duration as occurred in this case. The accidental injection of a hyperosmolar or toxic agent has been reported [9,10] and although it cannot be completely excluded in our case, it seems very improbable since the solutions were checked immediately before injection and there were no postoperative neurological sequelae. Mixing bupivacaine and fentanyl in the same syringe is our standard practice and has not caused any problems before.…”

Section: Discussionmentioning

confidence: 63%

Radicular acute pain after epidural anaesthesia with the technique of loss of resistance with normal saline solution

Gracia

Gomar

Riambau³

et al. 1999

Anaesthesia

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SummaryFatal oesophageal perforation occurred as a complication of elective general anaesthesia for cataract extraction in a 77-year-old female patient. Tracheal intubation had been achieved, albeit with difficulty, in the course of a clinical trial of the intubating laryngeal mask.Keywords Equipment; intubating laryngeal mask. Complications. ...................................................................................... Correspondence to: Dr M. A. Branthwaite Accepted: 30 May 1998 The laryngeal mask has found a useful place in anaesthetic practice both within and outside the hospital environment. A modified system, the intubating laryngeal mask, has been introduced recently to facilitate endotracheal intubation and a fatality resulting from its use is reported here. Case historyA 77-year-old female patient, ASA II, was scheduled for elective cataract extraction under general anaesthesia. Contralateral cataract extraction had been carried out uneventfully 8 months earlier under general anaesthesia involving controlled ventilation delivered through a size 4 laryngeal mask.On the evening before surgery, the patient consented orally to participate in a proposed trial of the intubating laryngeal mask. She received no written information about the trial and a designated consent form for participation was neither offered nor signed. A protocol for trial of a prototype intubating laryngeal mask had been cleared by the hospital Ethics Committee 3 years previously but had been deferred pending inclusion of the hospital in a multicentre trial of the definitive model. A draft protocol for the multicentre trial differed in a number of respects, most notably that it permitted a maximum of five attempts at intubation instead of two as proposed initially. The revised protocol had not been submitted to the local Ethics Committee.On the day of surgery, the patient was one of several on whom the technique of intubation through the definitive model of the intubating laryngeal mask was demonstrated. Difficulty was encountered in intubation, the mask was replaced at least once and intubation was only achieved successfully on the fifth attempt. Oesophageal intubation was suspected on the unsuccessful attempts. Blood was aspirated from the pharynx after intubation and a nasogastric tube, passed without difficulty to decompress the stomach, confirmed the presence of bleeding.Once awake, the patient complained of pain in the back and crepitus was noted in the neck. A chest X-ray about 3 h postoperatively showed air in the soft tissues and both sides of the mediastinum. There was a small effusion at the right base and some plate atelectasis at the left base. Oesophageal rupture was confirmed radiologically using a dilute solution of barium. The report described a fairly large oesophageal pouch arising from the posterior wall with a small amount of barium passing through a fistulous opening situated just below the neck of the pouch.A policy of conservative management was adopted but the patient's condition gave rise to increas...

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Section: Discussionmentioning

confidence: 63%

Radicular acute pain after epidural anaesthesia with the technique of loss of resistance with normal saline solution

Gracia

Gomar

Riambau³

et al. 1999

Anaesthesia

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“…Reports of permanent neurological deficits and death have also been reported. [34567] do Nascimento et al . had reported unintentional use of 19.1% KCl as diluents.…”

Section: Discussionmentioning

confidence: 99%

“…To reduce spinal cord edema, dexamethasone 10 mg IV was administered. The patient recovered completely within 12 h.[4]…”

Section: Discussionmentioning

confidence: 99%

“…It took approximately more than 12 h to recover fully. [347] In this case report, we used calcium gluconate and potassium binder along with supportive measures, and the patient recovered completely in 8 h.…”

Section: Discussionmentioning

confidence: 99%

“…[1] Normal saline (NS) is used as diluent for steroid and local anesthetic agent. [2] Inadvertent injection of potassium chloride (KCl) during anesthesia procedures is reported by many anesthesiologists;[345678] however, to the best of our knowledge, it has not been reported by orthopedic surgeons. Here, we report a case of paraplegia that developed after accidental use of KCl instead of NS as diluent along with methylprednisolone and local anesthetic.…”

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Inadvertent injection of potassium chloride instead of sodium chloride during treatment of chronic low back ache with epidural injection leading to paraplegia

Ranjan

Asif

Ahmad

et al. 2016

J Craniovert Jun Spine

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Epidural injection of steroid is given for back pain resistant to other conservative management. Normal saline (NS) is used as diluent in 80 mg methylprednisolone and a local anesthetic. Due to a similar looking ampoule of NS and potassium chloride (KCl), there is a probability of accidental use of KCl instead of NS. We present a case of a 50-year-old male patient having low back ache refractory to other conservative treatments. Epidural injection of steroid was given, but accidently KCl was mixed with methylprednisolone instead of NS. He developed severe cramps in the lower limbs, pruritus, and sweating, and finally paraplegia. Electrocardiography and blood showed features suggestive of hyperkalemia. He was given calcium gluconate and potassium chelating agent along with supportive measures. The patient recovered within 8 h. It is concluded that calcium gluconate and potassium chelating agent can be used if accidentally KCl is injected in epidural space.

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Immediate complications of regional blockade in obstetrics

Douglas¹,

Choi²

2000

Regional Analgesia in Obstetrics

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Inadvertent epidural administration of potassium chloride

Cited by 41 publications

References 8 publications

Radicular acute pain after epidural anaesthesia with the technique of loss of resistance with normal saline solution

Radicular acute pain after epidural anaesthesia with the technique of loss of resistance with normal saline solution

Inadvertent injection of potassium chloride instead of sodium chloride during treatment of chronic low back ache with epidural injection leading to paraplegia

Immediate complications of regional blockade in obstetrics

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