Acute transient spinal paralysis and cardiac symptoms following an accidental epidural potassium infusion - a case report

Accidental administration of tranexamic acid into the epidural space: a case report

PURPOSE

Tranexamic acid administration into the epidural space has not been previously reported. We describe our experience managing and investigating a drug error involving incorrect route of tranexamic acid administration through an epidural catheter.

CLINICAL FEATURES

A syringe containing tranexamic acid, intended for intravenous bolus and infusion intraoperatively using microbore tubing, was inadvertently attached to an epidural catheter via the Luer-type connector on the microbore tubing and epidural adapter.

CONCLUSIONS

Saline lavage of the epidural space may be considered if tranexamic acid has been administered into the epidural space. Early multidisciplinary team involvement combined with repeated postevent neurologic monitoring is recommended to guide therapy. Adoption of neuraxial route-specific connectors, when available, may be warranted to reduce Luer-type misconnections.

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

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

Narrative review of neuraxial potassium chloride administration errors: clinical features, human factors, and prevention measures

BACKGROUND

Administration of the wrong drug via the epidural or intrathecal route can cause devastating consequences. Because of the commonality of potassium replacement therapy coupled to its potential neurotoxic profile, we suspected that injuries related to this drug error would be present in the literature.

OBJECTIVES

We aimed to identify clinical characteristics associated with the inadvertent administration of potassium chloride (KCl) during neuraxial anesthesia. Our secondary objective was to identify human factors that may have been associated.

EVIDENCE REVIEW

Published reports of neuraxial administration of KCl in humans were searched using Medline and Google Scholar. Error reports in any language were included.

FINDINGS

25 case reports/series reported administration of KCl via epidural (25 patients) or intrathecal routes (three patients). There were six cases during interventional pain procedures, five cases in operating rooms and 17 in wards or intensive care units. Neuraxial KCl caused paraplegia in 22 patients. Mechanical ventilation was instituted in 11 of 28 patients. Three patients died. Epidural (eight patients) and spinal (two patients) lavage were performed to minimize consequences. A correctly prepared KCl infusion was connected to the epidural catheter for nine patients on wards (32%; 95% upper confidence limit: 48%) due to epidural-intravenous line confusion. Among the other 19 errors, KCl was confused with normal saline for 13 patients or local anesthetic in three patients. A wide range of concentrations and doses of KCl were administered. Variable use of intravenous steroid (13 patients) and epidural saline (eight patients) was found among patients who received epidural KCl. Human factors identified included incorrect visual perception, inadequate monitoring of infusions and substandard practice related to neuraxial anesthesia or analgesia.

CONCLUSIONS

KCl administration via epidural or intrathecal route has been reported to cause catastrophic consequences.

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

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.

Neuraxial and peripheral misconnection events leading to wrong-route medication errors: a comprehensive literature review

We conducted a search of the literature to identify case reports of neuraxial and peripheral nervous system misconnection events leading to wrong-route medication errors. This narrative review covers a 20-year period (1999-2019; English-language publications and abstracts) and included the published medical literature (PubMed and Embase) and public access documents. Seventy-two documents representing 133 case studies and 42 unique drugs were determined relevant. The most commonly reported event involved administering an epidural medication by an intravenous line (29.2% of events); a similar proportion of events (27.7%) involved administering an intravenous medication by an epidural line. Medication intended for intravenous administration, but delivered intrathecally, accounted for 25.4% of events. In the most serious cases, outcomes were directly related to the toxicity of the drug that was unintentionally administered. Patient deaths were reported due to the erroneous administration of chemotherapies (n=16), muscle relaxants (n=4), local anesthetics (n=4), opioids (n=1), and antifibrinolytics (n=1). Severe outcomes, including paraplegia, paraparesis, spinal cord injury, and seizures were reported with the following medications: vincristine, gadolinium, diatrizoate meglumine, doxorubicin, mercurochrome, paracetamol, and potassium chloride. These case reports confirm that misconnection events leading to wrong-route errors can occur and may cause serious injury. This comprehensive characterization of events was conducted to better inform clinicians and policymakers, and to describe an emergent strategy designed to mitigate patient risk.