Neurotoxic Myelitis Following Accidental Epidural Injection of Chlorhexidine During Obstetric Epidural Anesthesia: A Case Report

TL;DR

A woman developed severe spinal inflammation after chlorhexidine was accidentally injected during childbirth anesthesia, but she recovered with steroid treatment.

Contribution

This case report highlights the rare but severe neurotoxic effects of accidental chlorhexidine injection during epidural anesthesia.

Findings

Accidental epidural injection of chlorhexidine caused neurotoxic myelitis with paraplegia and respiratory distress.

Steroid therapy and monitoring led to rapid improvement and full functional recovery within a week.

The case underscores the importance of safety measures to prevent intrathecal drug administration errors.

Abstract

We report a case of neurotoxic myelitis following the accidental epidural injection of chlorhexidine during obstetric anesthesia at a peripheral hospital. A 32-year-old parturient in labor received an epidural catheter for vaginal delivery, during which 3 mL of chlorhexidine was mistakenly injected into the epidural space. This led to progressive paraplegia, severe headaches, and respiratory distress requiring intubation. The patient was subsequently transferred to our anesthesia and critical care department for further management. Radiological findings revealed centromedullary edema and myelitis. Her condition improved with steroid therapy to reduce the inflammatory response, along with strict monitoring. Paraplegia nearly resolved within 72 hours, with complete functional recovery one week later. This study highlights the serious risks of accidental intrathecal drug administration and underscores the need for heightened vigilance and safety measures in anesthesia practice.

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