Fatal bupivacaine overdose through intrathecally positioned epidural catheter

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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.

[1] Troop M. Negative aspiration for cerebral fluid does not assure proper placement of epidural catheter. AANA J. 1992, 60, 301-303

[2] Collier C. Total spinal or massive epidural block? [letter] Anaesth. Intensive Care 1998, 10, 92

[3] Druid H, Holmgren P. A compilation of fatal and control concentrations of drugs in postmortem femoral blood. J. Forensic. Sci. 1997, 42, 79-87

[4] Eklund A, Jonsson J, Schuberth J. A procedure for simulataneous screening and quantification of basic drugs in liver, utilizing capillary gas chromatography and nitrogen sensitive detection. J. Analyt. Toxicol. 1983, 7, 24-28

[5] Galet A, Fleyfel M, Beague D, Vansteenberghe F. Accidental spinal anaesthesia in obstetrics: limits of an epidural testdose. Ann. Fr. Anesth. 1992, 11, 377-380

[6] Suzuki N, Koganermaru M, Onizuka S, Takasaki M. Dural puncture with a 26-gauge spinal needle affects spread of epidural anaesthesia. Anesth. Analg. 1996, 82, 1040-1042

[7] Wilhelm S, Standl T, Burmeister M, Kessler G, Schulte am Esch J. Comparison of continuous spinal with combined spinal epidural anesthesia using plain bupivacaine 0,5% in trauma patients. Anesth. Analg. 1997, 85, 69-74

[8] Park R. A migrating epidural cannula [letter]. Anaesthesia 1984, 39, 289

[9] Holmström B, Rawal N, Axelsson K, Nydahl P-H. Risk of catheter migration during combined spinal epidural block: Percutaneous epiduroscopy study. Anesth. Analg. 1995, 80, 747-753

[10] Lin H-Y, Wu H-S, Peng T-H, Yeh YJ, Cheng IC, Lin IS, Liu CH. Pneumocephalus and respiratory depression after accidental dural puncture during epidural analgesia - a case report. Acta Anaesthesiol Sin. 1997, 35, 119-123

[11] Hardy PAJ. Can epidural catheters penetrate dura mater? An anatomical study. Anaesthesia 1986, 41, 1146-1147

[12] Naguib M, Magboul MMA, Samarkandi AH, Attia M. Adverse effects and drug interactions associated with local and regional anaesthesia. Drug Safety 1998, 18, 221-250

[13] de Jong RH, Bonin JD. Deaths from local anesthetic-induced convulsions in mice. Anesth. Analg. 1980, 59, 401-405

[14] Thomas RD, Behbehani MM, Coyle DE, Denson DD. Cardiovascular toxicity of local anesthetics: An alternate hypothesis. Anesth. Analg. 1986, 65, 444-450

[15] Reynolds F. A comparison of the potential toxicity of bupivacaine, lignocaine and mepivacaine during epidural blockade for surgery. Brit. J. Anaesth. 1971, 43, 567-572

[16] Rosenberg PH, Kalso EA, Tuominen MK, Lindén HB. Acute bupivacaine toxicity as a result of venous leakage under the tourniquet cuff during a Bier block. Anesthesiology 1983, 58, 95-98

Scandinavian Journal of Forensic Science

The Journal of Danish Society of Forensic Medicine

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