Accidental epidural catheter infusion of potassium chloride for postoperative analgesia: A case report

Abstract

An infusion of 100 cc of 0,2% potassium chloride was accidental performed through a thoracic epidural catheter, inserted to perioperative analgesia, to a 66 years old man who was scheduled for right hemicolectomy, 48 h after surgery. Paresis of upper limbs, flaccid paralysis of lower limbs and a sensitive level at T8 was observed. An epidural lavage with an initial dose of 20 cc of saline was slowly injected, followed for a saline infusion of 20 cc per hour. Neurologic signs were totally reverted some hours later and 24 h after the incident the physical exam was normal. We reviewed the clinical presentation of the complication and its mechanisms, the more frequent clinical evolution, as well as treatment measures and strategies to prevent the incident.

Keywords: Accidental infusion; Acute spinal cord injury; Catéter epidural; Complicaciones; Complications; Epidural catheter; Error de medicación; Infusión accidental; Lesión espinal aguda; Medication mistake; Potasio; Potassium chloride.