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

Infusión accidental de cloruro de potasio a través de un catéter epidural para analgesia postoperatoria: reporte de caso clínico.
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

Journal

Revista espanola de anestesiologia y reanimacion
ISSN: 2341-1929
Titre abrégé: Rev Esp Anestesiol Reanim (Engl Ed)
Pays: Spain
ID NLM: 101778594

Informations de publication

Date de publication:
18 Jun 2021
Historique:
received: 08 05 2020
revised: 25 08 2020
accepted: 11 10 2020
entrez: 22 6 2021
pubmed: 23 6 2021
medline: 23 6 2021
Statut: aheadofprint

Résumé

An infusion of 100cc of 0,2% potassium chloride was accidental performed through a thoracic epidural catheter, inserted to perioperative analgesia, to a 66years old man who was scheduled for right hemicolectomy, 48hours 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 20cc of saline was slowly injected, followed for a saline infusion of 20cc per hour. Neurologic signs were totally reverted some hours later and 24hours 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.

Identifiants

pubmed: 34154825
pii: S0034-9356(20)30290-5
doi: 10.1016/j.redar.2020.10.010
pii:
doi:

Types de publication

Case Reports

Langues

eng spa

Informations de copyright

Copyright © 2020 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado por Elsevier España, S.L.U. All rights reserved.

Auteurs

A Schwartzmann (A)

Departamento y Cátedra de Anestesiología, Hospital de Clínicas, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay.

A Rodríguez (A)

Departamento y Cátedra de Anestesiología, Hospital de Clínicas, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay.

P Castromán (P)

Departamento y Cátedra de Anestesiología, Hospital de Clínicas, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay. Electronic address: pablocastro227@gmail.com.

Classifications MeSH