| CASE REPORT |
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| Year : 2016 | Volume
: 7
| Issue : 4 | Page : 279-281 |
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Inadvertent injection of potassium chloride instead of sodium chloride during treatment of chronic low back ache with epidural injection leading to paraplegia
Rahul Ranjan1, Naiyer Asif2, Sohail Ahmad2, Syed Ifthekar3
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
Correspondence Address:
Rahul Ranjan
Department of Orthopaedics, Lady Hardinge Medical College, New Delhi - 110 001
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0974-8237.193265
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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. |
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