Dados do Trabalho

Título

Inadvertent intrathecal tranexamic acid administration: A mistake with potential catastrophic outcome

RESUMO

Case:
A 20-years-old pregnant woman was submitted to spinal anesthesia for an elective cesarean procedure at another hospital. She referred no anesthetic effect after administration of 15 mg bupivacaine, so an additional dose of 15 mg was used. The procedure was finished as usual, however, about 30 minutes later, the patient presented seizures refractory to the first approach with diazepam, and progressed to clinical status epilepticus (SE). There was no history of headache or hypertension during the pregnancy. Her prenatal was unremarkable. After reviewing all the infused drugs, the anesthetist noted that tranexamic acid was wrongly administered during the anesthetic procedure due to the first ampoule being wrongly relabed. She was sedated, submitted to orotracheal intubation, and transferred to our Intensive Care Unit. At the admission in our hospital, a new generalized tonic-clonic seizure was observed, so it was treated according to SE protocol. The electroencephalogram demonstrated a burst-suppression pattern due to sedatives. Sedation was progressively reduced until the patient woke up. She was discharged from the hospital some weeks later without cognitive sequels, using levetiracetam, which withdrawal was done at our outpatient clinic.
Discussion:
Tranexamic acid is an antifibrinolytic agent indicated in an obstetric scenario to control postpartum hemorrhage. Frequently anesthesiologists have this medication in their medicine box. Its adverse effects may vary from severe back pain and muscle spasm to hemodynamic instability, ventricular tachycardia, seizures and SE. There is no antidote to this drug, so the recommended management is to treat complications. Cephalo Spinal Fluid (CSF) lavage, a technique that consists of 10-20mL CSF drainage and infusing the same amount of preservative-free normal saline, is indicated in some cases. Although there are only a few studies considering this procedure, none of them were performed in patients with inadvertent intrathecal administration of tranexamic acid.
Final Comment:
Despite doubtless advances in patient health security, mistakes with catastrophic disclosures still occur. Even with many preventive strategies, the wrongly relabelled drug at the hospital pharmacy in association with the similar aspects of bupivacaine and tranexamic acid ampoules contributed to that. Thus, the relabel practice should be reviewed.

Palavras Chave

Inadvertent Intrathecal Infusion