Unintentional Infusion of Insulin Into the Epidural Space During Labor

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.