title: Inadvertent epidural administration of potassium chloride. A case report.
abstract: A 24-year-old black female presented for repeat elective Caesarean section. The procedure was performed under epidural anaesthesia. Sufentanil 25 micrograms, intended for postoperative analgesia, was inadvertently diluted to 10 ml with 15 per cent potassium chloride (KCl) instead of preservative-free normal saline (0.9 per cent NaCl). This solution was then injected via an epidural catheter into the epidural space at the conclusion of surgery. Two hours after injection of the sufetanil-KCl mixture, the patient had a level of sensory blockade to T1 and diaphoresis above this level. Painful muscle spasms had also developed below T1. One hour later she developed hypertension which required hydralazine 10 mg and labetalol 25 mg IV for treatment. The patient was treated supportively with oxygen. Dexamethasone 10 mg was administered intravenously to reduce spinal cord oedema. Intravenous diazepam 10 mg and meperidine 75 mg were given for sedation and analgesia. Complete recovery occurred within 12 hours.
authors.affiliation: Department of Anaesthesia, St. Boniface General Hospital, University of Manitoba, Winnipeg.
authors.forename: M J
authors.initials: MJ
authors.lastname: Tessler
authors.forename: I
authors.initials: I
authors.lastname: White
authors.forename: M
authors.initials: M
authors.lastname: Naugler-Colville
authors.forename: D R
authors.initials: DR
authors.lastname: Biehl
mesh_terms: D000328:Adult; D000767:Anesthesia, Epidural; D000773:Anesthesia, Obstetrical; D002585:Cesarean Section; D005260:Female; D005283:Fentanyl / Q000031:analogs & derivatives; D006801:Humans; D006973:Hypertension / Q000139:chemically induced; D008508:Medication Errors; D009128:Muscle Spasticity / Q000139:chemically induced; D010149:Postoperative Pain / Q000517:prevention & control; D011189:Potassium Chloride / Q000008:administration & dosage / Q000009:adverse effects*; D017409:Sufentanil
chemical_list: D011189:Potassium Chloride; D017409:Sufentanil; D005283:Fentanyl