In a 65 years old male patient 38 cc of a 7.45% potassium chloride-solution
was inadvertently infused within 3 hours into an epidural catheter on the
first postoperative day. The epidural potassium chloride administration res
ulted in a paresis and painful paraesthesia of the patient's legs and a lev
el of sensory blockade to TH 11. Furthermore vegetative symptoms like hyper
tension and tachycardia were observed. For therapy a single bolus of 40 mg
dexamethasone was administered intravenously followed by an epidural infusi
on of sodiumchloride 0,9% 99 cc/h for several hours. About 6 hours after th
e start of infusion all symptoms had disappeared. It is proposed that the u
se of colour-coded epidural catheter devices and coloured electrolyte solut
ions as well as infusion-pumps with a larger reservoir that reduce the freq
uency of syringe chan ges would be helpful in avoiding such complications.