Accidental Epidural Injection of Rocuronium in a Pediatric Patient: A Case Report and Literature Review

Abstract

Accidental administration of non-epidural drugs into the epidural or subarachnoid spaces may be associated with unexpected pain, morbidity, adverse effects, increased level of care, prolonged hospital stay, and mortality. We describe a 12-month-old admitted for secondary-stage hypospadias reconstruction. General anesthesia was induced with sevoflurane and a peripheral catheter was placed. Instead of ropivacaine, rocuronium (80 mg; 6.3 mg/kg) was injected into the epidural space by the caudal route. Surgery was uneventful and was completed 160 minutes after rocuronium was given. The patient exhibited paralysis with 1 of 4 twitches to the train-of-four with some posttetanic potentiation at the end of surgery. He was transferred to the pediatric intensive care unit for supportive ventilation and recovery. He did not experience oxygen desaturation or hypoventilation between the time of rocuronium administration and intubation. He was hemodynamically stable, without respiratory insufficiency, and his neurologic exam was normal, without motor or sensorial block. The patient was discharged home on the morning of the first postoperative day. Clinical examination 1 week after surgery revealed no lasting sequelae from the error.