What to do in case of accidental noradrenaline (norepinephrine) infusion into the epidural space?

Management of Accidental Noradrenaline Infusion into the Epidural Space

In case of accidental noradrenaline (norepinephrine) infusion into the epidural space, immediately stop the infusion, notify senior anesthesia staff, and administer phentolamine 5-10 mg diluted in 10 ml normal saline into the epidural catheter to counteract vasoconstriction. 1

Immediate Management

1. Stop the infusion immediately

2. Call for help - Notify senior anesthesia staff

3. Assess the patient:

   • Monitor vital signs (blood pressure, heart rate, oxygen saturation)
   • Assess neurological status (sensory and motor function)
   • Check for signs of cardiovascular instability

4. Administer antidote:

   • Inject phentolamine 5-10 mg diluted in 10 ml normal saline into the epidural catheter
   • Phentolamine is an alpha-adrenergic antagonist that will counteract the vasoconstriction caused by noradrenaline

5. Supportive measures:

   • Position patient appropriately (typically recumbent)
   • Provide supplemental oxygen if needed
   • Establish IV access if not already in place
   • Prepare for possible hemodynamic support

Monitoring and Follow-up

• Continuous cardiovascular monitoring
• Hourly neurological assessment including motor function (straight-leg raising test) 1
• Monitor for signs of spinal cord ischemia or neurological deficit
• Consider neurology consultation if neurological symptoms persist

Prevention Strategies

The accidental administration of non-epidural drugs into the epidural space is a preventable error that can have serious consequences. To prevent such incidents:

• Use clear labeling of all syringes and infusion bags
• Implement non-Luer lock connections for epidural catheters 2
• Ensure intrathecal catheters are clearly labeled adjacent to the filter and on any infusion pump 1
• Communicate verbally to all team members when an epidural or intrathecal catheter is in use 1
• Consider placing a notice on the patient's door indicating epidural/intrathecal catheter use 1

Important Considerations

• The risk of high- or total-spinal anesthesia exists if an epidural dose is inadvertently given through an intrathecal catheter 1
• Failure to aspirate CSF from a catheter does not exclude positioning within the subarachnoid space 1
• Medications administered through epidural or intrathecal catheters must be preservative-free and given through a filter connected to the catheter 1
• Only anesthetists should administer medications through an intrathecal catheter, and connect, disconnect or reconnect the catheter and tubing 1

Potential Complications

• Spinal cord ischemia due to vasoconstriction
• Neurological deficit (temporary or permanent)
• Cardiovascular instability
• Respiratory depression if the block extends high

This is a medical emergency that requires prompt recognition and treatment to minimize the risk of permanent neurological damage. The use of phentolamine as a specific antagonist to noradrenaline-induced vasoconstriction is the key intervention that may prevent serious morbidity and mortality.