title: [Inadvertent potassium chloride infusion in an epidural catheter].
abstract: In a 65 years old male patient 38 cc of a 7.45% potassium chloride-solution was inadvertently infused within 3 hours into an epidural catheter on the first postoperative day. The epidural potassium chloride administration resulted in a paresis and painful paraesthesia of the patient's legs and a level of sensory blockade to TH 11. Furthermore vegetative symptoms like hypertension and tachycardia were observed. For therapy a single bolus of 40 mg dexamethasone was administered intravenously followed by an epidural infusion of sodium chloride 0.9% 99 cc/h for several hours. About 6 hours after the start of infusion all symptoms had disappeared. It is proposed that the use of colour-coded epidural catheter devices and coloured electrolyte solutions as well as infusion-pumps with a larger reservoir that reduce the frequency of syringe changes would be helpful in avoiding such complications.
authors.affiliation: Abteilung für Anästhesiologie und Intensivmedizin, Evangelisches Krankenhaus Oberhausen.
authors.forename: P J
authors.initials: PJ
authors.lastname: Kulka
authors.forename: I
authors.initials: I
authors.lastname: Stratesteffen
authors.forename: R
authors.initials: R
authors.lastname: Grünewald
authors.forename: A
authors.initials: A
authors.lastname: Wiebalck
mesh_terms: D000368:Aged; D000767:Anesthesia, Epidural; D000893:Anti-Inflammatory Agents / Q000627:therapeutic use; D003907:Dexamethasone / Q000627:therapeutic use; D006801:Humans; D008297:Male; D019300:Medical Errors; D010243:Paralysis / Q000139:chemically induced / Q000188:drug therapy / Q000503:physiopathology; D010292:Paresthesia / Q000139:chemically induced / Q000188:drug therapy / Q000503:physiopathology; D011189:Potassium Chloride / Q000008:administration & dosage / Q000009:adverse effects*
chemical_list: D000893:Anti-Inflammatory Agents; D011189:Potassium Chloride; D003907:Dexamethasone