epidural steroid injections are commonly performed procedures in medicine by many specialties including orthopedics . normal
inadvertent injection of potassium chloride ( kcl ) during anesthesia procedures is reported by many anesthesiologists ; 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 .
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 .
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 ,
approximately over a period of 5 min , he developed progressive weakness of both the lower limbs .
his blood pressure was recorded as 210/110 mmhg and heart rate was 124 beats per minute .
labetalol was given immediately ; however , patient 's blood pressure was refractory to the treatment .
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 .
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 .
the patient became neurologically normal in the next 2 h. the patient was discharged the following day from the intensive care unit .
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 . kcl has often been confused with 0.9% ns because the two solutions have similar looking ampoules distinguished only by different colored writing
. different concentration of kcl injection leads to almost similar spectrum of symptoms and with full recovery .
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. tessler et al . reported that sufentanil 25 m , 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 .
sixty minutes later , she developed hypertension which responded well to hydralazine 10 mg and labetalol 25 mg intravenous ( iv ) .
the patient recovered completely within 12 h. 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 .
shanker et al . had reported a case in which 11.1% of kcl was accidently injected in epidural space .
lin et al . had correlated different epidural kcl concentrations with temporary or permanent sensory and motor deficits . in their study , rats had been used as a study model , and hence , it can not be applied for human .
mechanism of symptoms observed in epidural injection of potassium chloride in most of the cases reported , the method of treatment is supportive .
it took approximately more than 12 h to recover fully . in this case report , we used calcium gluconate and potassium binder along with supportive measures , and the patient recovered completely in 8 h.
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 .
 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 . 
Introduction
Case Report
Discussion
Conclusion
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