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Korean Journal of Anesthesiology 2008;55(1):104-106.
DOI: https://doi.org/10.4097/kjae.2008.55.1.104   
Accidental epidural injection of ephedrine: A case report.
Hyun seok Cho, Man jo Kim, Mun Cheol Kim, Dong jun Lee
Department of Anesthesiology and Pain Medicine, Seoul Paik Hospital, College of Medicine, Inje University, Seoul, Korea. manjo@medigate.net
We report a case of accidental epidural ephedrine injection. A 29-year-old male with left femoral artery occlusion was scheduled for thromboembolectomy. The operation was performed under epidural anesthesia. During the operation, ephedrine (30 mg/6 ml) was accidentally injected through epidural catheter instead of ropivacaine (45 mg/6 ml). Following the incident, we injected normal saline (10 ml) in the epidural space to dilute the solution. The patient had no complaint but blood pressure rose to 165/115 mmHg transiently. We observed the patient closely in recovery room and no further complication was found. In previous reports, various attempts have been tried to manage such incidents, but no definitive treatment for accidental injection is known. We present this case to remind the importance of confirming the drug everytime before injection.
Key Words: accidental epidural injection; ephedrine


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