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.
Meel
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Department of Forensic Medicine, University of Transkei, Umtata, South Africa.
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