Fatal arachnoiditis following accidental intradural injection of chlorhexidine: a case report and literature review.

Abstract

Chlorhexidine is the preferred antiseptic for skin preparation owing to its superior antimicrobial efficacy compared with povidone-iodine. However, its supposed neurotoxicity-particularly in combination with alcohol-can cause catastrophic damage if inadvertently introduced into the neuraxial space during epidural or spinal anesthesia. We describe a fatal case of arachnoiditis following unintentional intradural injection of alcohol-based chlorhexidine during epidural catheter placement for labor analgesia and report a literature review. Among 114 records, five case reports met the inclusion criteria. All patients were women receiving epidural or spinal anesthesia for obstetric or surgical procedures. Exposure involved either direct injection or contamination of anesthetic solutions with chlorhexidine. Onset ranged from immediate lumbar pain to delayed neurological deterioration. Reported outcomes included paraplegia, tetraplegia, hydrocephalus, syringomyelia, and profound functional loss. Therapeutic interventions-corticosteroids, neurosurgery, cerebrospinal fluid shunting, and analgesia-were ineffective in reversing deficits. Error prevention is essential and relies on the use of colored solutions, strict physical separation between chlorhexidine and other solutions used during procedures, the use of pre-impregnated applicators, or alternatively the use of naturally colored povidone-iodine, which may be less neurotoxic. Accidental intradural or epidural administration of chlorhexidine is a rare but devastating event most often associated with poor outcomes. Prevention requires mandating colored antiseptics or enforcing strict handling protocols.