Unintentional Infusion of Insulin Into the Epidural Space During Labor

TL;DR

A case where insulin was accidentally infused into a laboring woman's epidural space is reported, emphasizing the risks of wrong-route drug administration.

Contribution

Highlights a rare clinical error involving insulin in epidural infusion and advocates for route-specific connections to prevent such incidents.

Findings

Insulin was unintentionally administered into the epidural space without causing neurological damage.

The case underscores the underreported risk of wrong-route drug administration during labor.

No long-term complications were observed despite the presence of potentially neurotoxic preservatives in the insulin.

Abstract

Inadvertent injection of drugs into the epidural space has a potential for serious morbidity and is probably underestimated and underreported.

A 39-year-old female with no medical history presented for delivery. An epidural catheter was requested and correctly placed. Continuous epidural infusion was chosen for labor analgesia. Six hours after the parturient complained about inefficient analgesia, a syringe swap with insulin was identified.

Despite the risk of possibly neurotoxic preservatives in the insulin formulation, no neurological sequelae were observed.

This case highlights the issue of wrong-route drug administration and the urgent need to adopt route-specific connections.