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Accidental Epidural Injection of Pancuronium

Krataijan, Janjira MD; Laeni, Nawal MD

doi: 10.1213/01.ANE.0000151471.73967.52
Letters to the Editor: Letters & Announcements

Department of Anesthesiology; Faculty of Medicine; Prince of Songkla University; Hadyai, Thailand;

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To the Editor:

A 41-year-old man, 51 kg, ASA status I, was scheduled for anteroposterior resection due to cancer of the rectum. Combined epidural-general anesthesia was planned. The epidural catheter was successfully placed at L2–3 interspace through the 18-gauge Tuohy needle after the “ loss of resistance to air technique.”

Before induction of general anesthesia, pancuronium (4 mg) was accidentally injected through epidural catheter instead of fentanyl 100 μg.

After induction of general anesthesia with thiopental 5 mg/kg, the syringe of pancuronium that was prepared for intubation was found to be empty. The trachea was then intubated after IV pancuronium 0.1 mg/kg and anesthesia was maintained with N2O, O2, halothane. Neuromuscular blockade was monitored by acceleromyography using train-of-four (TOF-watch®, Organon (Ireland) Ltd, Swords, Dublin, Ireland) mode. The operation was uneventful and lasted for 3 h. No added neuromuscular blockade for the entire procedure after the first dose. The patient started to breath spontaneously during suturing the skin. Neuromuscular blockade was reversed with IV neostigmine 0.04 mg/kg and atropine 0.02 mg/kg at the end of the operation. TOF ratios were 0.4 after 10 min and 0.86 after 25 min, respectively. The trachea was extubated 30 min later.

He was discharged from the PACU at the 7th postoperative hour without any adverse effects and from the hospital on the 14th postoperative day. He had been followed up for 2 months and there were no clinical signs of neurotoxicity.

Local anesthetics, opioids, and steroids are commonly injected into the epidural space in medical practice. In the history of regional anesthesia, various substances have been accidentally injected into epidural space, with consequences ranging from no clinical effect to irreversible paralysis (1–4). To our knowledge, no data about accidental injection of pancuronium through an epidural catheter in human were documented in the literature. In this report, we administered pancuronium both IV and epidurally. We found that the time from injection of pancuronium epidurally to recovery at TOF ratio of 0.86 was 230 min while the action of pancuronium injected IV was normally lasted for 60–90 min (5). No data on the rate of absorption of pancuronium from the epidural space was found in the literature. Neuromuscular blocking drugs cause excitement and seizures when introduced into the central nervous system (6–8). Acute intrathecal administration of these drugs leads to dose-dependent central nervous system effects in the rat (6). Because no clinical or experimental data exist about interaction between pancuronium and other drugs injected epidurally, no other drugs should be given at this site.

Although we injected saline into the epidural space to accelerate systemic absorption of pancuronium (“volume effect”), there is no sufficient evidence in the literature that this maneuver is effective (9).

In conclusion, the anesthesiologist must be careful during administration of the anesthesia, as human error can be catastrophic to the care of patients.

Janjira Krataijan, MD

Nawal Laeni, MD

Department of Anesthesiology; Faculty of Medicine; Prince of Songkla University; Hadyai, Thailand;

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