[Inadvertent potassium chloride infusion in an epidural catheter]

Anaesthesist. 1999 Dec;48(12):896-9. doi: 10.1007/s001010050803.
[Article in German]


In a 65 years old male patient 38 cc of a 7.45% potassium chloride-solution was inadvertently infused within 3 hours into an epidural catheter on the first postoperative day. The epidural potassium chloride administration resulted in a paresis and painful paraesthesia of the patient's legs and a level of sensory blockade to TH 11. Furthermore vegetative symptoms like hypertension and tachycardia were observed. For therapy a single bolus of 40 mg dexamethasone was administered intravenously followed by an epidural infusion of sodium chloride 0.9% 99 cc/h for several hours. About 6 hours after the start of infusion all symptoms had disappeared. It is proposed that the use of colour-coded epidural catheter devices and coloured electrolyte solutions as well as infusion-pumps with a larger reservoir that reduce the frequency of syringe changes would be helpful in avoiding such complications.

Publication types

  • Case Reports
  • English Abstract

MeSH terms

  • Aged
  • Anesthesia, Epidural*
  • Anti-Inflammatory Agents / therapeutic use
  • Dexamethasone / therapeutic use
  • Humans
  • Male
  • Medical Errors*
  • Paralysis / chemically induced
  • Paralysis / drug therapy
  • Paralysis / physiopathology
  • Paresthesia / chemically induced
  • Paresthesia / drug therapy
  • Paresthesia / physiopathology
  • Potassium Chloride / administration & dosage
  • Potassium Chloride / adverse effects*


  • Anti-Inflammatory Agents
  • Potassium Chloride
  • Dexamethasone