Inadvertent epidural administration of ceftriaxone in a post-cesarean section patient during analgesia top-up

A 28-year-old ASA II woman underwent elective cesarean section under epidural anesthesia (15 mL 0.5% bupivacaine with 4 µg/mL fentanyl at L3-L4). Postoperatively, she received epidural analgesia with 0.1% bupivacaine plus fentanyl infusion and 1 g IV ceftriaxone 12 hourly for prophylaxis. Six hours after delivery, a nurse inadvertently injected 1 g (10 mL of 10%) ceftriaxone epidurally instead of local anesthetic, due to an unlabeled syringe mix-up.

Immediately, the patient experienced severe pain at the site of incision and lumbar region Numeric Rating Scale (NRS 10/10), with blood pressure rising from 118/68 to 156/92 mmHg and heart rate from 76 to 112 bpm, consistent with intense pain and sympathetic surge rather than direct neurotoxicity. IV pentazocine 30 mg and IM diclofenac 75 mg resolved pain within 3 minutes; moderate sedation (Ramsay 3) occurred but resolved quickly, with vitals stabilizing (Blood Pressure, BP 124/74 mmHg; Heart Rate, HR 88 bpm). Neurological examination remained normal. The epidural filter was flushed with 5 mL saline, and analgesia resumed safely after 30 minutes. No neurological deficits, fever, or infection developed over 48 hours of monitoring; she was discharged on day 4 with no sequelae at 18-weeks follow-up.

This case illustrates medication errors in obstetric units and contrasts the benign outcome of epidural cephalosporin exposure (mild, transient symptoms) with severe risks of intrathecal administration. Strict safety protocols are essential.