Inadvertent intrathecal administration of potassium chloride during routine spinal anesthesia: case report.
During routine spinal anesthesia, an ampule of potassium chloride, instead of bupivacaine, was mistakenly opened and inadvertently administered intrathecally to a patient, resulting in pain, cramps, and death within 2.5 hours of injection. We discuss the medicolegal implications of such an error and possible preventive measures pertaining to this case.
Department of Forensic Medicine, University of Transkei, Umtata, South Africa.
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Meel
D000328:Adult; D000775:Anesthesia, Spinal / Q000009:adverse effects*; D001929:Brain Edema / Q000139:chemically induced; D002585:Cesarean Section; D017809:Fatal Outcome; D005260:Female; D006801:Humans; D007278:Injections, Spinal; D011189:Potassium Chloride / Q000008:administration & dosage / Q000506:poisoning*
D011189:Potassium Chloride