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Case Report
Accidental epidural injection of Atropine
Udayan Bakshi
MGM Medical College and LSK Hospital, Kishungunj, Bihar, India
ABSTRACT
Intrathecal injection of drugs for anesthesia, regional analgesia, and chronic pain management are common practice now. Local anesthetic,
adjuvants, and opioids are in common use. Human error in the Operation Theater and the Intensive Care Unit setup is also known
and reported, due to stress and overwork. A case of unintentional atropine injection intrathecally, which was closely observed for any
untoward effects, is reported here.
Key words: Accidental intrathecal injection, atropine, epidural
Introduction
The intrathecal injection instills the drug directly into
the cerebrospinal fluid and thus into the central nervous
system by passing the blood–brain barrier. Drugs used
in such a fashion are usually local analgesic or analgesic
adjuvant drugs and some chemotherapeutic agents. Drugs
that are not meant to be used intrathecally, if injected,
can result in temporary or permanent neurological
injury, including death. Nevertheless human error does
occur and sometimes even occurs more than once.[1] Such
unfortunate accidents should be followed closely for a
sufficient length of time to prevent immediate and late
disasters. Reporting of such cases gives an insight to other
professionals about the possible hazards and sequences.
This helps to formulate an effective management, which
is prognostically very important.
Case Report
A sixty-four-year-old female was undergoing total knee
arthroplasty under combined spinal epidural analgesia.
It was planned to do a double puncture combined spinal
epidural block in a sitting posture. The epidural block
was done at the lumber second and third interspace with
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an 18 SWG Tuohy needle, where an epidural catheter was
threaded for a length of about 4 cm inside the epidural
space and kept in situ for perioperative analgesia. A
subarachnoid block was performed at the lumber three
and four interspace with a 25 SWG Quincke tip spinal
needle, and 0.5% Bupivacaine 2 ml was injected spinally.
The patient was allowed to lie down. An epidural injection
of 2% Xylocaine with adrenaline 10 ml was injected.
Intravenous fluid was started beforehand and infusion
of a balanced salt solution (Ringer lactate) 500 ml and
colloid (6% tetrastarch) 500 ml was allowed to run
freely and continued. The surgery started after antibiotic
administration and application of a tourniquet, dressing,
and draping. Injection Clonidine hydrochloride 75 mcg
was injected epidurally for prolonging analgesia and also
to improve the quality of analgesia.[2]
Soon afterward, the patient presented with a fall in blood
pressure to less than 90 mmHg systolic with a pulse
rate of less than 60 beats per minute. A bolus dose of
phenylephrine 0.1 mg was injected to raise the blood
pressure. Even as the blood pressure got corrected the pulse
rate fell further down to less than 50 beats per minute.
Injection atropine 1 ml (0.6 mg / ml) was drawn into a
syringe and was planned to be injected intravenously to
correct the bradycardia. In a hurry the injection atropine
was pushed epidurally, accidentally. The anesthesiologist
Address for correspondence:
Prof. Udayan Bakshi,
MGM Medical College and LSK Hospital,
Kishungunj, Bihar, India.
E-mail: udayan.bakshi@gmail.com
Indian Journal of Pain | January-April 2013 | Vol 27 | Issue 1
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Bakshi: Accidental epidural injection of Atropine
realized it once more than half milliliter of atropine was
injected epidurally. The atropine syringe was disconnected
from the epidural catheter and the remaining half milliliter
was discarded. The patient was observed closely for any
untoward immediate effect of the drug. It was also tried
not to inject any more atropine. However, the bradycardia
persisted even three minutes after injecting atropine
epidurally and a further dose of 0.6 mg atropine was
injected intravenously to correct the bradycardia. The
signs and symptoms of central anticholinergic syndrome
was searched for, which arose as a central nervous system
manifestation of anti-muscarinic effects of different drugs,
when they cross the blood–brain barrier.[3-5] As in this case
atropine was instilled directly into the central nervous
system, bypassing the blood–brain barrier, manifestations
of the central anticholinergic syndrome were expected.
However, the patient did not show any such signs or
symptoms. The surgery took two-and-half hours when the
analgesic effects of the initial bolus doses persisted. The
usual protocol of continuing the epidural with infusion
of 0.25% Ropivacaine and fentanyl 2 mcg / ml at a rate of
5 – 12 ml per hour with the help of a syringe pump, without
disrupting the analgesia, was also followed in this case. The
patient was shifted to a High Dependency Unit with the
usual postoperative directions. The patient stayed in the
High Dependency Unit for the next 48 hours. The epidural
catheter was removed after 48 hours and the patient was
shifted into the ward. She was discharged home after 12
days of surgery, uneventfully.
The lady was observed and examined for any sensory
or motor deficit at the time of discharge and during her
subsequent visits to the Orthopedic Clinic. She was further
requested to meet her anesthesiologist three months
after surgery during her routine orthopedic check up,
for a further neurological evaluation, which was within
normal limits.
Discussion
This case was unique in the respect of human error using
a very common drug with central nervous system activity.
Vigilance and color coding of ampules prevents this
situation. Color coding of ampules are not mandatory in
India. Although 31 reports of 37 cases were found on the
internet, none reported epidural atropine.[1] The initial
reaction of the anesthesia team was to expect a central
anticholinergic syndrome, which was expected, but did
not happen in this case. The second cause for monitoring
was to observe if epidural atropine could increase the
pulse rate and correct bradycardia, which again did not
Indian Journal of Pain | January-April 2013 | Vol 27 | Issue 1
happen. The third reason for observation was to see
whether atropine could shorten the duration of spinal
analgesia, as it was seen that adjuvant drugs that increase
the level of acetylcholine-like neostigmine prolong central
analgesia.[6] Although it was not observed properly, for a
given clinical time the duration or the quality of analgesia
was not compromised. The patient was also monitored for
any long-term ill effects after three months, but fortunately
it did not happen in this case.
Conclusion
When a drug has been injected accidentally many measures
have been taken without any proven benefit,[7,8] like epidural
catheter aspiration, lavage of epidural space, and epidural
or systemic corticosteroid administration. However,
some anesthetists have provided only symptomatic and
supportive care, if required.[9] The present team only
followed that principle.
The anesthesia team got lucky this time that a human error
did not cause any permanent damage to the patient and
when disclosed to the surgeon and the patient it did not
cause any professional or emotional distrust.
References
1. Hew CM, Cyna AM, Simmons SW. Avoiding inadvertent
epidural injection of drugs intended for non-epidural use.
Anaesth Intensive Care 2003;31:44-9.
2. Huang YS, Lin LC, Huh BK, Sheen MJ, Yeh CC, Wong
CS, et al. Epidural Clonidine for postoperative pain after
total knee arthroplasty: A dose response study. Anesth Analg
2007;104:1230-5.
3. Cook B, Spence AA. Postoperative central anticholinergic
syndrome. Eur J Anesthesiol 1997;14:1-2.
4. Kessel J. Atropine premedication. Anaesth Intensive Care
1974;2:77-80.
5. Viby-Mogensen J. Central anticholinergic syndrome or
postoperative residual block? Eur J Anesthesiol 2000;17:466-7.
6. Liu SS, Hodgeson PS, Moore JM, Trautman WJ, Burkhead
DL. Dose-response effects of spinal neostigmine added to
bupivacaine spinal anesthesia in volunteers. Anesthesiology
1999;90:710-7.
7. Cay DL. Accidental epidural thiopentone. Anaesth Intensive
Care 1984;12:61-3.
8. Brownridge P. More on epidural thiopentone. Anaesth Intensive
Care 1984;12:270-1.
9. Shanker KB, Palker NV, Nishkala R. Paraplegia following
epidural potassium chloride. Anaesthesia 1985;40:45-7.
How to cite this article: Bakshi U. Accidental epidural injection of
Atropine. Indian J Pain 2013;27:44-5.
Source of Support: Nil. Conflict of Interest: None declared.
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