Inadvertent epidural injection of potassium chloride. Report of two cases

Acta Anaesthesiologica Scandinavica
K Liu, Y Y Chia

Abstract

Two patients underwent thoracotomy for resection of pulmonary or esophageal carcinoma. Postoperatively, epidural catheters were inserted for pain management. Complaints of severe injection pain over the abdomen or lower extremities were made during one administration of pain medication. Progressive weakness and numbness developed over the lower trunk and lower extremities, with subsequent respiratory difficulties. Potassium chloride (KCl) was suspected to have been mistaken for normal saline as the diluent for morphine. In addition to endotracheal intubation and ventilatory support, steroids were administered both intravenously and epidurally to suppress spinal cord irritation. The two patients regain motor and sensory functions 14 and 18 hours later, respectively, without sequelae.

References

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Nov 1, 1988·Canadian Journal of Anaesthesia = Journal Canadien D'anesthésie·M J TesslerD R Biehl
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Citations

Apr 1, 1996·Acta Anaesthesiologica Scandinavica·M Vercauteren, V Saldien
Jul 1, 1996·Acta Anaesthesiologica Scandinavica·M Vercauteren, V Saldien
Sep 13, 2001·European Journal of Anaesthesiology·R J LitzD M Albrecht
Jan 12, 2013·Acta Anaesthesiologica Scandinavica·M T PitkänenJ G Förster
Aug 6, 1999·European Journal of Anaesthesiology·V A PedutoF Gori
Dec 6, 2005·Paediatric Anaesthesia·P Courrèges
Jun 23, 2021·Revista española de anestesiología y reanimación·A SchwartzmannP Castromán

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