Korean J Anesthesiol.  2008 Jul;55(1):104-106. 10.4097/kjae.2008.55.1.104.

Accidental epidural injection of ephedrine: A case report

• Cho HS
• Kim MJ
• Kim MC
• Lee DJ

• KMID: 1782529
• DOI: http://doi.org/10.4097/kjae.2008.55.1.104

Abstract

We report a case of accidental epidural ephedrine injection. A 29-year-old male with left femoral artery occlusion was scheduled for thromboembolectomy. The operation was performed under epidural anesthesia. During the operation, ephedrine (30 mg/6 ml) was accidentally injected through epidural catheter instead of ropivacaine (45 mg/6 ml). Following the incident, we injected normal saline (10 ml) in the epidural space to dilute the solution. The patient had no complaint but blood pressure rose to 165/115 mmHg transiently. We observed the patient closely in recovery room and no further complication was found. In previous reports, various attempts have been tried to manage such incidents, but no definitive treatment for accidental injection is known. We present this case to remind the importance of confirming the drug everytime before injection.

Keyword

accidental epidural injection; ephedrine

MeSH Terms

Adult
Amides
Anesthesia, Epidural
Blood Pressure
Catheters
Ephedrine
Epidural Space
Femoral Artery
Humans
Injections, Epidural
Male
Recovery Room
Amides
Ephedrine