Accidental Intrathecal Injection Research Articles

Accidental intrathecal injection of tranexamic acid: a case report

BackgroundTranexamic acid is a well-known antifibrinolytic medication frequently prescribed to individuals with bleeding disorders. Following accidental intrathecal injection of tranexamic acid, major morbidities and fatalities have been documented. The aim of this case report is to present a novel method for management of intrathecal injection of tranexamic acid.Case presentationIn this case report, a 400 mg intrathecal injection of tranexamic acid resulted in significant back and gluteal pain, myoclonus of the lower limbs, agitation, and widespread convulsions in a 31-year-old Egyptian male with history of left arm and right leg fracture. Immediate intravenous sedation with midazolam (5 mg) and fentanyl (50 μg) was delivered with no response in seizure termination. A 1000 mg phenytoin intravenous infusion and subsequently, induction of general anesthesia was performed by thiopental sodium (250 mg) and atracurium (50 mg) infusion, and the trachea of the patient was intubated. Maintenance of anesthesia was achieved by isoflurane 1.2 minimum alveolar concentration and atracurium 10 mg every 20 minutes, and subsequent doses of thiopental sodium (100 mg) to control seizures. The patient developed focal seizures in the hand and leg, so cerebrospinal fluid lavage was done by inserting two spinal 22-gauge Quincke tip needles, one on level L2–L3 (drainage) and the other on L4–L5. Intrathecal normal saline infusion (150 ml) was done over an hour by passive flow. After cerebrospinal fluid lavage and the patient’s stabilization was obtained, he was transferred to the intensive care unit.ConclusionsEarly and continuous intrathecal lavage with normal saline, with the airway, breathing, and circulation protocol is highly recommended to decrease morbidity and mortality. The selection of the inhalational drug as a sedative and for brain protection in the intensive care unit provided possible benefits in management of this event with medication errors.

Refractory status epilepticus after accidental intrathecal injection of tranexamic acid

Tranexamic acid (TXA) is an antifibrinolytic agent that is commonly used in cardiac, gynecologic, and obstetric surgeries. Inadvertent intrathecal injection of the TXA may lead to serious side effects including myoclonus, seizure, and ventricular fibrillation. So far, the proconvulsive properties of TXA and its mechanism of action are poorly understood. Medical error leads to serious adverse effects that can be attributed to similar appearance of ampoules, location of ampoules, and incorrect labeling of prefilled syringes. We herein report a case of refractory status epilepticus after accidental intrathecal injection of TXA. The patient was treated with thiopentone infusions until achieving a burst suppression pattern on electroencephalogram along with other antiepileptic drugs. Subsequently, the patient recovered completely without any neurological deficit. To the best of our knowledge, this is the first case of refractory status epilepticus after inadvertent intrathecal injection of TXA. Such catastrophic complications can be avoided by vigilance, correct labeling of syringes and ampoules, double checking medications prior to administration, and preventing manufacturing of vials of different drugs with similar appearance.

Accidental intrathecal injection of dopamine hydrochloride resulting in analgesic effects.

Accidental intrathecal injection of dopamine hydrochloride resulting in analgesic effects.

Color Flow Doppler Ultrasonography Can Distinguish Caudal Epidural Injection from Intrathecal Injection

Color flow Doppler ultrasonography has been used to confirm caudal epidural injection, but its ability to detect accidental intrathecal injection is unknown. We hypothesized that, when using color flow Doppler, the injection of fluid into the epidural space would result in turbulent flow which would appear as a burst of color while intrathecal injection would show an absence of a color flow Doppler signal. Two groups of pediatric patients (up to 6 years of age) were prospectively enrolled for this observational study during a 2-month period. One group (group E) consisted of patients suitable for elective surgery using caudal epidural analgesia, and the other (group I) included patients receiving lumbar puncture for intrathecal chemotherapeutic injection. After induction of general anesthesia and placement of the patient in the lateral position, an 8 MHz curved array probe (Sonosite TITAN, Bothell, WA) was applied to obtain a transverse image of the lumbar region (L1-L3). Real-time images using color flow Doppler were obtained and recorded during initial injections of 2 consecutive (20 seconds apart) aliquots of 0.1 mL/kg medication of local anesthetic (0.25% bupivacaine) or chemotherapy drugs (mixture of methotrexate, cytarabine, and hydrocortisone) at a rate of 0.5 to 1.0 mL/s. After obtaining the study images, the rest of the medication was injected in standard fashion. A blinded anesthesiologist later evaluated the recorded images to determine a positive or negative result (positive = presence of turbulence as illustrated by a medley of color; negative = no turbulence or color). Sensitivity, specificity, and positive and negative predictive values were calculated for those patients who had successful analgesia (group E) and intrathecal (group I) injections. Forty recorded images from 41 patients (group E, n = 21; group I, n = 20) were included in the analysis. The observed sensitivity, specificity, positive predictive value, and negative predictive values were all 100%. The lower 95% confidence limits were 0.832. In the context of this study, color flow Doppler could differentiate epidural from intrathecal injection into the caudal space of children up to 6 years of age using a 0.1 mL/kg injection volume and injection rate of 0.5 to 1.0 mL/s.

Medication error: Subarachnoid injection of tranexamic acid

Some factors have been identified as contributing to medical errors, such as labels, appearance and location of ampoules. We present a case of accidental injection of tranexamic acid instead of Bupivacaine during spinal anaesthesia. One minute after the injection of 3 mL of the solution, the patient developed myoclonus of her lower extremities. Accidental intrathecal injection of the wrong drug was suspected and a used ampoule of tranexamic acid was discovered in the trash can. The ampoules of Bupivacaine (5 mg/mL, trade name “Sensovac Heavy”) and tranexamic acid (500 mg/mL, Trade name “Nexamin”) were similar in appearance. Her myoclonus was successfully treated with phenytoin, sodium valproate, thiopental sodium infusion, midazolam infusion and supportive care of haemodynamic and respiratory systems. The surgery was temporarily deferred. The patient's condition progressively improved to full recovery.

Accidental Intrathecal Injection of Aminophylline in Spinal Anesthesia

Accidental Intrathecal Injection of Aminophylline in Spinal Anesthesia

Inadvertent intrathecal injection of atracurium

This report relates how tracurium was given by mistake, intrathecally, during spinal anesthesia, to a 38-year-old woman, who was a candidate for abdominal hysterectomy. When no analgesia was observed, the mistake in giving the injection was understood. She was evaluated postoperatively by train of four ratio, measuring her breathing rate, eye opening, and protruding of tongue at one, two, twenty-four, and forty-eight hours, and then at one and two weeks, with the final evaluation the following month. The patient had normal timings during the operation and postoperation periods, and no abnormal findings were observed through the first month. This finding was contrary to several studies, which described adverse reactions due to accidental intrathecal injection of neuromuscular blocking drugs.

Intrathecal Vincristine

We report 3 cases of accidental intrathecal vincristine administration. All 3 patients died between 8 and 18 days after the incident because of decerebration. In the literature, we found 41 cases of accidental intrathecal injection of vincristine. These reports represent only a fraction of the existing problem. New in our report is the fact that the first 2 cases were attributed to viral infection, only after the detection of high levels of vincristine in the cerebrospinal fluid was the real cause of death ascertained. The third case occurred during the implementation of rules by the Dutch Childhood Oncology Group on how to handle intrathecal triple therapy; and despite sequential safety measures, the accident still occurred. In the Netherlands no more accidents of this nature have occurred in children after the introduction of a quadruple syringe system 8 years ago. In our opinion the best fail-safe solution would be the development of a unique connection that is incompatible with a standard Luer syringe.

Polymyoclonus Seizure Resulting from Accidental Injection of Tranexamic Acid in Spinal Anesthesia

We present a case of accidental injection of tranexamic acid instead of bupivacaine during spinal anesthesia. One minute after intrathecal injection of 3.5 mL of solution, the patient developed myoclonus of his lower extremities. Accidental intrathecal injection of the wrong drug was suspected and a used ampule of tranexamic acid discovered in the trash can. The ampules of tranexamic acid (500 mg/5 mL) and bupivacaine (5 mg/mL, Merck, Darmstadt, Germany) were similar in appearance. General anesthesia was induced. Ten hours later, the patient developed myoclonus of his upper extremities and face. His polymyoclonus was successfully treated with phenytoin, sodium thiopental infusion, sodium valproate and supportive care of the hemodynamic, and respiratory systems. The patient's condition progressively improved to full recovery.

Prolonged Paralysis Caused by Accidental Intrathecal Injection of Neo Vitacain®: report of two cases

Prolonged Paralysis Caused by Accidental Intrathecal Injection of Neo Vitacain^®: report of two cases

Inadvertent intrathecal vincristine administration: a neurosurgical emergency

Vincristine has a high neurotoxicity level. If given intrathecally by accident, it can cause ascending radiculomyeloencephalopathy, which is almost always fatal. The authors report a rare case in which vincristine was accidentally injected intrathecally into a 32-year-old man. The patient, who had Burkitt lymphoma, was neurologically intact, and it is likely that his survival was made possible due to aggressive neurosurgical therapy. After immediate cerebrospinal fluid (CSF) aspiration, external ventricular and lumbar drains were placed for CSF irrigation, which was continued for 6 days. This CSF irrigation was combined with 1) the intrathecal administration of fresh-frozen plasma to bind the vincristine and 2) an intravenous antineurotoxic therapy involving pyridoxine, folic acid, and glutamic acid. The patient's first sensorimotor deficits occurred after 2 days, led to an incomplete sensorimotor dysfunction below T-9 within the next 17 days, but progressed no further. Supported by the scarce data culled from the reviewed literature, the authors hypothesize that prolonged CSF irrigation combined with antineurotoxic therapy contributed to the patient's satisfactory outcome. In conclusion, accidental intrathecal vincristine injection requires emergency and adequate neurosurgical therapy.

1562 Accidental intrathecal injection of epidural blood patch with extensive subarachnoid dissemination of blood and vertebrobasilar vasospasm: a case report

1562 Accidental intrathecal injection of epidural blood patch with extensive subarachnoid dissemination of blood and vertebrobasilar vasospasm: a case report

Calpain Inhibitor-like Fraction in Rabbit Cerebrospinal Fluid is probably an Oligopeptide

We have proved before that μ-calpain can be a promising autogenous agent to replace chymopapain in chemonucleolysis treatment. Even in the case of accidental intrathecal injection, the undesirable neural damage of calpaincan be neutralized by normal cerebrospinal fluid (CSF). The aim of this study was to characterize this unknown calpain inhibitor-like component in the CSF of normal rabbits. A heat-stable low molecular weight fraction in the CSF was identified. It was not extracted by chloroform solution, but labile to protease digestion. It inhibited the calpain proteolysis of microtubule-associating protein-2 (MAP-2) and membrane structure proteins of platelets and PC12 cells. It can block the autolytic activation of native human erythrocyte μ-calpain, where the conversion of the large subunit of μ-calpain from the 80-kDa form to the 76-kDa form was obstructed, with accumulation of the intermediate 78-kDa form. A possible calpain inhibition mechanism was discussed. After purification by paper chromatography, gel filtration and reverse phase chromatography, the composition of the calpain inhibitor was investigated. An oligopeptide with molecular weight about 800 Da was identified as a novel calpain inhibitor by partial amino acid sequence.

Evaluation of S1 motor block to determine a safe, reliable test dose for epidural analgesia

Accidental intrathecal injection of bupivacaine during epidural analgesia in labour remains a hazard, with the potential to cause total spinal anaesthesia and maternal collapse. Sacral block appears early after intrathecal injections compared with epidural ones, and we therefore used SI motor block to determine a safe and reliable test dose for epidural catheter misplacement. Mothers booked for elective Caesarean section were given various intrathecal doses of bupivacaine with fentanyl during routine combined spinal-epidural anaesthesia. Using sequential allocation we found that the ED50 for SI motor block 10 min after intrathecal injection was bupivacaine 7 mg with fentanyl 14 micrograms (95% CI, 6.2-7.8 mg). We then used intrathecal bupivacaine 13 mg to look for the ED95. We found the calculated ED97.5 to be bupivacaine 9.7 mg with fentanyl 19.4 micrograms (95% CI, 8.7-11.4). We conclude that testing for SI motor block 10 min after epidural injection of bupivacaine 10 mg is a reliable test to detect accidental intrathecal injection in the obstetric population.

Calpain inhibition by cerebrospinal fluid and effects of calpain on intrathecal nerve tissue.

The effects of calpain on intrathecal nerve tissue in the rabbit were investigated. To evaluate the chemonucleolytic side effect of calpain on nerve tissue in the event of accidental intrathecal calpain injection. Calpain has a degradative effect on proteoglycans, and as previously shown, it is associated with chemonucleolytic action in the rabbit. However, its effect on nerve tissue in the event of accidental intrathecal injection is not clear. The inhibitory activity of cerebrospinal fluid against calpain was measured in human cerebrospinal fluid using mu-calpain, and in different cerebrospinal fluid fractions separated by molecular filtration. The presence of the endogenous calpain inhibitor, calpastatin, in human cerebrospinal fluid was examined by Western blotting with anticalpastatin antibody. After intrathecal application of calpain in rabbits, the spinal cord nerve tissue was examined by light microscopy. Cerebrospinal fluid inhibited the enzyme reaction of calpain at its normal concentration. Immunoblotting with anticalpastatin antibody did not yield positive staining. After the intrathecal application of calpain, there was no evidence of degeneration in the nerve tissue of the spinal cord. This study suggests that in the event of accidental intrathecal injection of calpain for chemonucleolysis, the enzyme activity of calpain will be neutralized by cerebrospinal fluid, and the calpain should not cause unwanted side effects in chemonucleolysis.

Avoid Errors with Look-Alike Products Patients Still at Risk of Accidental Intrathecal Vincristine Injection

These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them in your inservice training programs. Your assistance is required to continue this feature. The reports described here were received through the USP Medication Errors Reporting Program, which is presented in cooperation with the Institute of Safe Medication Practices. If you have encountered medication errors and would like to report them, you may call USP toll-free, 24 hours a day, at 1-800-233-7767 (1-800-23-ERROR). Any reports published by ISMP will be anonymous. Comments are also invited; the writer's names will be published if desired. ISMP may be contacted at the address shown below.

Epidural block for obstetrics: Comparison of bolus injection of local anesthetic with gravity flow technique

Study Objective: To test the hypothesis that slow administration of local anesthetic into the epidural space by gravity flow reduces the incidence of signs and symptoms of unintended injection. Design: Prospective, randomized study. Setting: Teaching hospital. Patients: 600 ASA physical status I and II parturients scheduled for labor and delivery or elective cesarean section. Interventions: After identification of the epidural space with pulsations of an air-fluid column, parturients for vaginal delivery (n = 380) were randomized to receive a test dose of 3 ml 3% 2-chloroprocaine with epinephrine 20 μg, two doses of 7 ml bupivacaine 0.03 % with sufentanil 1 μg/ml and epinephrine 2 μg/ml by either gravity flow (Group 1) given over 30 seconds or by bolus injection (Group 2) given over 5 seconds through the epidural needle; parturients for Cesarean delivery (n = 220) were randomized to receive a test dose and two doses of 6 ml lidocaine 2 % with sufentanil 1 μg/ml and epinephrine 2 μg/ml by either gravity flow or by bolus injection through the epidural needle. Changes in maternal heart rate (HR) and blood pressure, signs of intravascular injection, and adverse effects of epidural bupivacaine-sufentanil were recorded after each dose. Measurements and Main Results: Gravity flow administration (Group 1) was associated with a smaller increase in mean maternal HR ( p < 0.001), less hypotension ( p < 0.01), sedation ( p < 0.01), nausea ( p = 0.01), and segmental spread ( p < 0.0001) than were corresponding doses given by traditional bolus injection (Group 1) for vaginal or Cesarean deliveries. The incidence of systemic toxicity was zero of 300 (0%) with gravity flow and 4 of 300 (1.3%) by bolus injection, p = 0.12, Fisher's exact test. No patient in either group had an accidental intrathecal injection. Conclusion: Gravity flow administration of local anesthetic-opioid solution during epidural block for obstetrics was associated with fewer signs of systemic drug absorption and cardiovascular perturbations than was the traditional bolus injection. This study supports the current opinion that slow administration of local anesthetic during epidural black contributes to fewer adverse events.

Accidental intrathecal injection of ionic water-soluble contrast medium: report of a case, including treatment

Accidental intrathecal injection of ionic water-soluble contrast medium: report of a case, including treatment

Pharmacologic Aspects of Local Anesthetic Use

Summary LAs reversibly interrupt transmission of nerve impulses by inhibiting function of the sodium channel. Large myelinated rapidly conducting A fibers are most sensitive, and small unmyelinated slowly conducting C fibers, least sensitive to the block of transmission. Pregnancy may increase even further the A-fiber sensitivity to conduction block. Of the clinically useful LAs, bupivacaine has become extremely popular in obstetric anesthesia because of its ability to create high quality analgesia with a minimum degree of motor block. The ability to cause this type of differential block is highly desirable and new LAs such as ropivacaine are evaluated with this in mind. Epinephrine is a useful addition to LA solutions for purposes of detecting accidental intravascular injections and for improving the quality and duration of block, reducing the total amount of LA needed. However, there is a risk of temporary decrease in IVBF when accidental intravascular injection of epinephrine-containing solutions occurs. Alkalinization of LA solutions with sodium bicarbonate enhances nerve block experimentally and may have a beneficial effect clinically. Similarly, carbonated lidocaine may have clinical advantages over lidocaine hydrochloride. LA effects on the neonate have been evaluated by neurobehavioral testing. Inconsistent results and a failure to consider the multiplicity of factors surrounding parturition make it difficult to determine the clinical significance of these data. Regarding the adverse effects of LAs, bupivacaine cardiotoxicity has been related to its fast-in, slow-out blocking of myocardial sodium channels. The pregnant animal may be more sensitive to this effect than the nonpregnant animal. Chloroprocaine has been reformulated without the anti-oxidant bisulfite, which along with the low pH of the earlier preparation is thought to have been responsible for the cases of neurotoxicity associated with accidental intrathecal injection of the drug. Whenever large amounts of LA are used, there is the potential for the development of toxicity. The practitioner must strive to prevent LA toxicity but must remain alert to the possibility of its occurrence and be prepared to initiate effective treatment.

Effects of epidural and intrathecal application of collagenase in the lumbar spine: an experimental study in rabbits.

An experimental model is described in which collagenase in different concentrations and volumes were applied epidurally or intrathecally in the rabbit lumbar spine. This made it possible to study the tissue effects in a situation similar to that of collagenase leaking from a disc or accidental epidural or intrathecal injection at chemonucleolysis. Epidurally applied collagenase, in higher concentration, caused a local thinning of the dura. This effect was reduced at lower concentrations and volumes. Intrathecally injected collagenase, even in small amounts, caused intrathecal hemorrhage and acute paraplegia in the hind limbs. Therefore, in the clinical situation, intrathecal injection of collagenase must be avoided.