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Inadvertent epidural infusion of paracetamol in a child

P Courrèges1

  • 1Anesthèsie pédiatrique, Hôpital Saint Vincent de Paul, Bd de Belfort BP, Lille Cedex, France. courreges.philippe@ghicl.net

Paediatric Anaesthesia
|December 6, 2005
PubMed

Insights

A medication error occurred when paracetamol was inadvertently administered via epidural infusion instead of intravenous, causing headache and vomiting in a pediatric patient. This highlights the need for vigilance in medication administration to prevent such incidents.

Area of Science:

  • Anesthesiology
  • Pediatric Pain Management
  • Medication Safety

Background:

  • Lumbar epidural anesthesia was administered to an 11-year-old boy for severe lower limb burn analgesia.
  • A dural puncture occurred during the initial epidural catheter placement, necessitating a second attempt.

Observation:

  • Postoperatively, the patient received continuous epidural analgesia and intravenous infusions via separate pumps.
  • A nurse mistakenly injected paracetamol into the epidural catheter instead of the intravenous line on two separate occasions.

Findings:

  • The patient developed headache and vomiting, presumed to be mechanical complications.
  • Symptoms resolved with saline, caffeine, and supportive care; neurological examinations remained normal.
  • This case represents the first reported instance of paracetamol administration via epidural route.

Implications:

  • Medication administration errors, particularly with epidural infusions, may be underreported.
  • Enhanced protocols and double-checks are crucial to prevent inadvertent epidural drug administration.
  • This incident underscores the importance of distinguishing between intravenous and epidural infusion pumps to ensure patient safety.

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