<abstract xmlns="http://www.w3.org/1999/xhtml"><p> We describe a fatality due to an intrathecally positioned epidural catheter and an infusion rate of bupivacaine set 10 times higher than planned. The undetected misplacement, despite safety routines, is discussed along with the toxicological findings and new information on the intrathecal distribution of bupivacaine. From a clinical point of view, the human factor, in combination with an indistinct decimal point on the pump, was considered as the reason for the unfortunate overdose. In continuous epidural infusion of local anesthetics, the importance of guidelines and informed staff in managing complications of epidural lumbar infusion as well as careful monitoring of the vital functions is essential. Guidelines are also vital during the procedure of insertion of epidural catheters. When using combined spinal and epidural anaesthesia, we believe that an epidural catheter should be inserted, and its position tested, prior to spinal anesthesia. The case also illustrates the need of innovative investigation techniques to confirm the suspicion of unusual manifestations of inadvertent drug effects. Segmental analysis, together with analyses in a control case, enabled us to elucidate the high and varying tissue concentrations in the central nervous system.</p></abstract>

We describe a fatality due to an intrathecally positioned epidural catheter and an infusion rate of bupivacaine set 10 times higher than planned. The undetected misplacement, despite safety routines, is discussed along with the toxicological findings and new information on the intrathecal distribution of bupivacaine. From a clinical point of view, the human factor, in combination with an indistinct decimal point on the pump, was considered as the reason for the unfortunate overdose. In continuous epidural infusion of local anesthetics, the importance of guidelines and informed staff in managing complications of epidural lumbar infusion as well as careful monitoring of the vital functions is essential. Guidelines are also vital during the procedure of insertion of epidural catheters. When using combined spinal and epidural anaesthesia, we believe that an epidural catheter should be inserted, and its position tested, prior to spinal anesthesia. The case also illustrates the need of innovative investigation techniques to confirm the suspicion of unusual manifestations of inadvertent drug effects. Segmental analysis, together with analyses in a control case, enabled us to elucidate the high and varying tissue concentrations in the central nervous system.

Fatal bupivacaine overdose through intrathecally positioned epidural catheter

Section of Forensic Medicine, Dept of Community Medicine and Rehabilitation, Umeå University, PO Box 7642, SE-907 12 Umeå, Sweden

Dept of Surgical and Perioperative Sciences, Umeå University, SE-901 85 Umeå, Sweden

Scandinavian Journal of Forensic Science

{"article-title":"Fatal bupivacaine overdose through intrathecally positioned epidural catheter"}

We describe a fatality due to an intrathecally positioned epidural catheter and an infusion rate of bupivacaine set 10 times higher than planned. The...

Fatal bupivacaine overdose through intrathecally positioned epidural catheter

Published Online: May 28, 2013

Page range: 10 - 12

DOI: https://doi.org/10.2478/sjfs-2013-0003

Keywords
Guidelines, Spinal cord, Toxicology

This content is open access.

Fatal bupivacaine overdose through intrathecally positioned epidural catheter

Published Online: May 28, 2013

Page range: 10 - 12

DOI: https://doi.org/10.2478/sjfs-2013-0003

KeywordsGuidelines, Spinal cord, Toxicology

This content is open access.

Keywords
Guidelines, Spinal cord, Toxicology