A 75-year-old woman with a history of type II DM and insulin treatment with chronic complications such as polyneuropathy, hypertension in treatment and obesity was scheduled for total knee replacement surgery.
In the preoperative data there is nothing remarkable apart from what has been described, the anesthetic technique was a combined epidural/intradural procedure at L3-L4 level, and through the intradural needle 3 ml of 0.5% bupivacaine was administered.
The postoperative period was uneventful and the patient was transferred to the plant with an epidural PCAE (EAP) loaded with 0.125 bupivacaine and 4 micrograms fentanyl per ml, with a programming of 3 ml.h-1, bolus.
At 4 a.m. approximately PCA is changed causing error and epidurally administering PCA with medication and programming for iv route (in 100 ml, 50 mg morphine metamizole plus 10 mg).
When passing the daily visit of the UDAP, the nurse of that unit detects the error.
The patient is conscious and oriented with excellent analgesia, without data of respiratory depression, neurological alterations or other side effects.
The amount of drug administered was 4 mg morphine and 160 mg metamizole.
This PCA and the catheter were removed and the patient was admitted to the resuscitation unit for control and follow-up, where the patient did not have any side effects and remained stable at all times, so 24 hours later the anesthesiologist was discharged.
A periodical follow-up of up to 18 months was carried out without any incidence.
