Intradural chlorhexadine

[epidural man]

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I trained at Virginia Mason, and shortly before I got there - there was a case where the IR physician injected chlorhexidine IV, and the patient eventually died. It was a warning to all of us.

And why people would still pour colorless chlorhexidine into a procedure tray is completely beyond me.

https://rapm.bmj.com/content/early/2026/03/04/rapm-2026-107636

 

[epidural man]

Client Challenge

 

[clubdeac]

Seattles a crazy place to begin with

 

[willabeast]

Long time ago (previous century) someone put something toxic ( probably alcohol because they eventually smelled it) into a container that was supposed to be for irrigation. Patient lost the leg. It was a really bad complicated fracture, external fixation etc. Last time I saw the patient was anesthesia for an amputation. No idea if it resulted in litigation.

 

[Orin]

So no injecting bleach either?

 

[Laryngospasm]

Lots of cases out there of inadvertent IT or epidural injection of various chemicals or medications. They are almost always really bad outcomes. Many not out in the public. I can think of four that I know of personally.
Best practice is to eliminate the possibility within reason. So no liquid chlorhexidine, no meds from outside the spinal kit or epidural kit. Greatly reduces the chances of this: during ob anes or anes using epidural cath or other keep any toxic meds out of easy reach and preferably locked in the pixis or whatever you use so that you have to actively think about what you are doing before injecting the medication ie don’t keep concentrated phenylephrine or any other med right next to your 10cc of morphine where they can be mistakenly swapped.
From what I have seen way more of this with anesthesia than pain due the differences in the way they are practiced.

 

[mille125]

Lots of cases out there of inadvertent IT or epidural injection of various chemicals or medications. They are almost always really bad outcomes. Many not out in the public. I can think of four that I know of personally.
Best practice is to eliminate the possibility within reason. So no liquid chlorhexidine, no meds from outside the spinal kit or epidural kit. Greatly reduces the chances of this: during ob anes or anes using epidural cath or other keep any toxic meds out of easy reach and preferably locked in the pixis or whatever you use so that you have to actively think about what you are doing before injecting the medication ie don’t keep concentrated phenylephrine or any other med right next to your 10cc of morphine where they can be mistakenly swapped.
From what I have seen way more of this with anesthesia than pain due the differences in the way they are practiced.

agree

 

[Baron S]

Saw a case of inadvertent epidural ketamine. Dude ended up okay but almost became the Kwisatz Haderach there for a few hours.