Abstract
Medication errorsare still one of the contributing factors leading to morbidity and mortality in anesthesia, despite measures to ensure patient safety. A 14-year-old male inadvertently received intrathecal tranexamic acid instead of hyperbaric bupivacaine for an elective herniorrhaphy. Shortly after induction, patient complained of severe back and lower limb pain, restlessness, tachycardia, hypertension, and generalized myoclonic seizures.
Highlights
Medication errors continue to be a leading cause of morbidity and mortality even in industrialized countries, despite vigilance in anesthesia practice
We report the accidental injection of tranexamic acid (TXA) into the subarachnoid space due to similarity in appearance between the ampules of the drug and hyperbaric bupivacaine for spinal anesthesia, leading to severe pain in the back and both lower limbs, hypertension, tachycardia, and generalized myoclonic seizures
Tranexamic acid at a therapeutic dose of 1 g intravenously will result in a cerebrospinal fluid (CSF) concentration of 0.9 mcg/L 9 hours after administration; the injection of a similar dose through a normal CSF volume would be expected to produce a concentration in the CSF 7000 times higher or approximately 6,600 mcg/mL
Summary
Medication errors continue to be a leading cause of morbidity and mortality even in industrialized countries, despite vigilance in anesthesia practice. We report the accidental injection of tranexamic acid (TXA) into the subarachnoid space due to similarity in appearance between the ampules of the drug and hyperbaric bupivacaine for spinal anesthesia, leading to severe pain in the back and both lower limbs, hypertension, tachycardia, and generalized myoclonic seizures. Three minutes after the patient was placed in the supine position, he became restless and complained of severe pain in both lower limbs and back. His pulse rate and blood pressure increased to 130 bpm and 160/100 mmHg, respectively. An hour after intrathecal administration of the wrong drug, the patient developed generalized myoclonic seizures. The patient was subsequently discharged after two weeks of hospital admission with no neurological deficits
Sign-in/Register to view highlights & summary Sign-in/Register to access full text options 
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a callMore From: Journal of Clinical Anesthesia and Pain Management
Disclaimer: All third-party content on this website/platform is and will remain the property of their respective owners and is provided on "as is" basis without any warranties, express or implied. Use of third-party content does not indicate any affiliation, sponsorship with or endorsement by them. Any references to third-party content is to identify the corresponding services and shall be considered fair use under The CopyrightLaw.
