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Journal of Craniovertebral Junction and Spine
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CASE REPORT
Year : 2016  |  Volume : 7  |  Issue : 4  |  Page : 279-281  

Inadvertent injection of potassium chloride instead of sodium chloride during treatment of chronic low back ache with epidural injection leading to paraplegia


1 Department of Orthopaedics, Lady Hardinge Medical College, New Delhi, India
2 Department of Orthopaedics, J. N. Medical College, AMU, Aligarh, Uttar Pradesh, India
3 Department of Orthopaedics, Hindu Rao Medical College, New Delhi, India

Date of Web Publication2-Nov-2016

Correspondence Address:
Rahul Ranjan
Department of Orthopaedics, Lady Hardinge Medical College, New Delhi - 110 001
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-8237.193265

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   Abstract 

Epidural injection of steroid is given for back pain resistant to other conservative management. Normal saline (NS) is used as diluent in 80 mg methylprednisolone and a local anesthetic. Due to a similar looking ampoule of NS and potassium chloride (KCl), there is a probability of accidental use of KCl instead of NS. We present a case of a 50 year old male patient having low back ache refractory to other conservative treatments. Epidural injection of steroid was given, but accidently KCl was mixed with methylprednisolone instead of NS. He developed severe cramps in the lower limbs, pruritus, and sweating, and finally paraplegia. Electrocardiography and blood showed features suggestive of hyperkalemia. He was given calcium gluconate and potassium chelating agent along with supportive measures. The patient recovered within 8 h. It is concluded that calcium gluconate and potassium chelating agent can be used if accidentally KCl is injected in epidural space.

Keywords: Epidural injection; low back pain; paraplegia; potassium chloride.


How to cite this article:
Ranjan R, Asif N, Ahmad S, Ifthekar S. Inadvertent injection of potassium chloride instead of sodium chloride during treatment of chronic low back ache with epidural injection leading to paraplegia. J Craniovert Jun Spine 2016;7:279-81

How to cite this URL:
Ranjan R, Asif N, Ahmad S, Ifthekar S. Inadvertent injection of potassium chloride instead of sodium chloride during treatment of chronic low back ache with epidural injection leading to paraplegia. J Craniovert Jun Spine [serial online] 2016 [cited 2018 Nov 19];7:279-81. Available from: http://www.jcvjs.com/text.asp?2016/7/4/279/193265


   Introduction Top


Epidural steroid injections are commonly performed procedures in medicine by many specialties including orthopedics.[1] Normal saline (NS) is used as diluent for steroid and local anesthetic agent.[2] Inadvertent injection of potassium chloride (KCl) during anesthesia procedures is reported by many anesthesiologists;[3],[4],[5],[6],[7],[8] however, to the best of our knowledge, it has not been reported by orthopedic surgeons. Here, we report a case of paraplegia that developed after accidental use of KCl instead of NS as diluent along with methylprednisolone and local anesthetic. Injection was given through caudal route in the sacral hiatus. The purpose of this case report is to diagnose the case, to approach for its management, and to caution the beginner regarding its occurrence if utmost attention is not given before injecting a drug.


   Case Report Top


A 50 year old male patient presented to us with L5 nerve root radiculopathy, conservative managements such as nonsteroidal anti inflammatory drugs and physiotherapy after which epidural administration of 80 mg of methylprednisolone was planned. Our routine method of epidural injection is to take 80 mg of methylprednisolone and 2 ml of 2% lignocaine in 20 ml of syringe and to dilute it up to 20 ml using 0.9% NS. After aseptic preparation of the local site, the previously prepared solution was injected into the sacral hiatus using a 22 gauge needle. Immediately after injection, the patient started complaining of severe pain in both the lower limbs. Pain was associated with pruritus, severe cramps, and profuse sweating. Approximately over a period of 5 min, he developed progressive weakness of both the lower limbs. On further clinical examination, the patient had complete flaccid paraplegia below T11 level. Below T11, all the reflexes were absent. On further examination, his blood pressure was recorded as 210/110 mmHg and heart rate was 124 beats per minute.

The patient was shifted to medicine emergency immediately. For high blood pressure, labetalol was given immediately; however, patient’s blood pressure was refractory to the treatment. Sweating and agitation continued. Electrocardiography showed features suggestive of hyperkalemia such as tachycardia, absent P wave, and tall T wave. We reviewed the medication administered and found that instead of NS, 15% KCl was used as diluents by a junior assistant by mistake. The patient was shifted to the Intensive Care Unit. All supportive measures were given. In addition to supportive measures, membrane stabilizing agent calcium gluconate was used. Blood samples showed normal studies, except raised potassium levels (7 mg/dL). Potassium chelating agent (Ksylate) was used to decrease potassium concentration in the blood. After 2 h of treatment, blood pressure and heart rate returned to normal levels. Return of sensory modalities occurred after 6 h, and by that time, the patient had developed spasticity. There was exaggeration of deep tendon reflexes and extensor plantar reflex. The patient became neurologically normal in the next 2 h. The patient was discharged the following day from the Intensive Care Unit.


   Discussion Top


The sacral hiatus provides the most caudal and direct route of entry to the epidural space and allows for the administration of steroid based solutions for the treatment of lumbar pathology. Advantages of the caudal approach are a dramatically decreased incidence of dural puncture.[9]

KCl has often been confused with 0.9% NS because the two solutions have similar looking ampoules distinguished only by different colored writing.[3],[4]

Different concentration of KCl injection leads to almost similar spectrum of symptoms and with full recovery. Reports of permanent neurological deficits and death have also been reported.[3],[4],[5],[6],[7] do Nascimento et al. had reported unintentional use of 19.1% KCl as diluents. The patient developed lower limbs warmness, increase heart rate, raised blood pressure, intense pruritus on the chest, agitation, increased sensory and motor blocks, and respiratory failure secondary because of pulmonary edema, and the patient required ventilatory support. The patient recovered totally after 24 h.[3]

Tessler et al. reported that sufentanil 25 µm, meant for postoperative analgesia, was inadvertently diluted to 10 ml with 15% KCl instead of 0.9% NS and was then injected through an epidural catheter into the epidural space in the postoperative room. The patient developed sensory blockade to T1 spinal level and diaphoresis above this level. Sixty minutes later, she developed hypertension which responded well to hydralazine 10 mg and labetalol 25 mg intravenous (IV). The patient was treated supportively with oxygen. To reduce spinal cord edema, dexamethasone 10 mg IV was administered. The patient recovered completely within 12 h.[4]

Liu et al. reported two patients who underwent thoracotomy for resection of pulmonary or esophageal carcinoma. Postoperatively, accidently KCl was mixed with morphine and was injected through epidural catheters for pain management. The patient complains severe injection pain over the lower extremities or the abdomen, followed by progressive weakness and numbness over the lower extremities and lower abdomen, and subsequent respiratory difficulties. In addition to endotracheal intubation and ventilatory support, steroids were administered both IV and epidurally to suppress spinal cord irritation. Both the patients regained motor and sensory functions 14 and 18 h later, respectively, without any sequela.[7]

Sometimes, KCl injection leads to neurological deficit for a few months. Shanker et al. had reported a case in which 11.1% of KCl was accidently injected in epidural space. The patient recovered from paraplegia in 6 months.[6]

Lin et al. had correlated different epidural KCl concentrations with temporary or permanent sensory and motor deficits.[5] In their study, rats had been used as a study model, and hence, it cannot be applied for human.

Mechanism of development of symptoms has been proposed. It is tabulated in [Table 1].
Table 1: Mechanism of symptoms observed in epidural injection of potassium chloride

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In most of the cases reported, the method of treatment is supportive. It took approximately more than 12 h to recover fully.[3],[4],[7] In this case report, we used calcium gluconate and potassium binder along with supportive measures, and the patient recovered completely in 8 h.


   Conclusion Top


Paraplegia after unintentional epidural administration of KCl is reversible more often than not if diagnosed early and treated immediately. The method of treatment is mostly supportive and symptomatic, but recovery can be enhanced with the use of membrane stabilizing agents and potassium binders. Our recommendation is to always read the ampoule information carefully before using any drug.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.[10]

 
   References Top

1.
Cohen SP, Bicket MC, Jamison D, Wilkinson I, Rathmell JP. Epidural steroids: A comprehensive, evidence based review. Reg Anesth Pain Med 2013;38:175 200.  Back to cited text no. 1
    
2.
Kim D, Brown J. Efficacy and safety of lumbar epidural dexamethasone versus methylprednisolone in the treatment of lumbar radiculopathy: A comparison of soluble versus particulate steroids. Clin J Pain 2011;27:518 22.  Back to cited text no. 2
    
3.
do Nascimento P Jr., Módolo NS, Meletti JF, Braz JR. Sympathetic hyperactivity, respiratory failure, pruritus, and anesthesia after unintentional epidural injection of potassium chloride: Case report. Reg Anesth Pain Med 1998;23:219 22.  Back to cited text no. 3
    
4.
Tessler MJ, White I, Naugler Colville M, Biehl DR. Inadvertent epidural administration of potassium chloride. A case report. Can J Anaesth 1988;35:631 3.  Back to cited text no. 4
    
5.
Lin D, Becker K, Shapiro HM. Neurologic changes following epidural injection of potassium chloride and diazepam: A case report with laboratory correlations. Anesthesiology 1986;65:210 2.  Back to cited text no. 5
    
6.
Shanker KB, Palkar NV, Nishkala R. Paraplegia following epidural potassium chloride. Anaesthesia 1985;40:45 7.  Back to cited text no. 6
    
7.
Liu K, Chia YY. Inadvertent epidural injection of potassium chloride. Report of two cases. Acta Anaesthesiol Scand 1995;39:1134 7.  Back to cited text no. 7
    
8.
Vercauteren M, Saldien V. Epidural injection of potassium hydrochloride. Acta Anaesthesiol Scand 1996;40:505.  Back to cited text no. 8
    
9.
Conn A, Buenaventura RM, Datta S, Abdi S, Diwan S. Systematic review of caudal epidural injections in the management of chronic low back pain. Pain Physician 2009;12:109 35.  Back to cited text no. 9
    
10.
Garrison JC. Histamine, bradykinin, 5 hydroxytryptamine, and their antagonists. In: Gilman AG, Rall TW, Nies AS, Taylor P, editors. The Pharmacological Basis of Therapeutics. 8th ed. Elmsford: Pergamon Press; 1990. p. 575 82.  Back to cited text no. 10
    



 
 
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