• Am J Forensic Med Pathol · Sep 1998

    Case Reports

    Inadvertent intrathecal administration of potassium chloride during routine spinal anesthesia: case report.

    • B Meel.
    • Department of Forensic Medicine, University of Transkei, Umtata, South Africa.
    • Am J Forensic Med Pathol. 1998 Sep 1;19(3):255-7.

    AbstractDuring routine spinal anesthesia, an ampule of potassium chloride, instead of bupivacaine, was mistakenly opened and inadvertently administered intrathecally to a patient, resulting in pain, cramps, and death within 2.5 hours of injection. We discuss the medicolegal implications of such an error and possible preventive measures pertaining to this case.

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