Refractory status epilepticus after inadvertent intrathecal injection of tranexamic acid treated by magnesium sulfate
Highlights • Accidental intrathecal injection of tranexamic acid is reported. • Refractory seizures were terminated with magnesium sulfate. • Always verify medications before administration. • Teamwork and communication are important during emergencies.
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| Published in: | International journal of obstetric anesthesia Vol. 26; pp. 71 - 75 |
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| Abstract | Highlights • Accidental intrathecal injection of tranexamic acid is reported. • Refractory seizures were terminated with magnesium sulfate. • Always verify medications before administration. • Teamwork and communication are important during emergencies. |
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| AbstractList | Highlights • Accidental intrathecal injection of tranexamic acid is reported. • Refractory seizures were terminated with magnesium sulfate. • Always verify medications before administration. • Teamwork and communication are important during emergencies. We present a case of accidental injection of tranexamic acid during spinal anesthesia for an elective cesarean delivery. Immediately following intrathecal injection of 2mL of solution, the patient complained of severe back pain, followed by muscle spasm and tetany. As there was no evidence of spinal block, the medications given were checked and a 'used' ampoule of tranexamic acid was found on the spinal tray. General anesthesia was induced but muscle spasm and tetany persisted despite administration of a non-depolarizing muscle relaxant. Hemodynamic instability, ventricular tachycardia, and status epilepticus developed, which were refractory to phenytoin, diazepam, and infusions of thiopental, midazolam and amiodarone. Magnesium sulfate was administered postoperatively in the intensive care unit, following which the frequency of seizures decreased, eventually stopping. Unfortunately, on postoperative day three the patient died from cardiopulmonary arrest after an oxygen supply failure that was not associated with the initial event. This report underlines the importance of double-checking medications before injection in order to avoid a drug error. As well, it suggests that magnesium sulfate may be useful in stopping seizures caused by the intrathecal injection of tranexamic acid. •Accidental intrathecal injection of tranexamic acid is reported.•Refractory seizures were terminated with magnesium sulfate.•Always verify medications before administration.•Teamwork and communication are important during emergencies. We present a case of accidental injection of tranexamic acid during spinal anesthesia for an elective cesarean delivery. Immediately following intrathecal injection of 2mL of solution, the patient complained of severe back pain, followed by muscle spasm and tetany. As there was no evidence of spinal block, the medications given were checked and a ‘used’ ampoule of tranexamic acid was found on the spinal tray. General anesthesia was induced but muscle spasm and tetany persisted despite administration of a non-depolarizing muscle relaxant. Hemodynamic instability, ventricular tachycardia, and status epilepticus developed, which were refractory to phenytoin, diazepam, and infusions of thiopental, midazolam and amiodarone. Magnesium sulfate was administered postoperatively in the intensive care unit, following which the frequency of seizures decreased, eventually stopping. Unfortunately, on postoperative day three the patient died from cardiopulmonary arrest after an oxygen supply failure that was not associated with the initial event. This report underlines the importance of double-checking medications before injection in order to avoid a drug error. As well, it suggests that magnesium sulfate may be useful in stopping seizures caused by the intrathecal injection of tranexamic acid. |
| Author | Hatch, D.M Herschmiller, E.J Owen, M.D Atito-Narh, E Olufolabi, A.J |
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| BackLink | https://www.ncbi.nlm.nih.gov/pubmed/26775897$$D View this record in MEDLINE/PubMed |
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| Cites_doi | 10.4103/1119-3077.127563 10.1213/ane.0b013e3181a04d69 10.1124/jpet.301.1.168 10.4103/1658-354X.76504 10.1097/00000542-200301000-00042 10.1213/ANE.0b013e3181c92b23 10.1213/ANE.0000000000000464 10.1155/2012/646028 10.1097/PTS.0b013e31823d048d 10.1111/j.1365-2044.2004.04062.x 10.4103/0019-5049.96335 10.1213/01.ane.0000250436.17786.72 10.1161/STROKEAHA.108.527788 10.1159/000115131 10.1097/ALN.0b013e318210483d |
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| Keywords | Tranexamic acid Medication error Magnesium Cesarean section Spinal anesthesia |
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| References_xml | – volume: 17 start-page: 226 year: 2014 end-page: 231 ident: b0015 article-title: Audit of medication errors by anesthetists in North Western Nigeria publication-title: Niger J Clin Pract contributor: fullname: Mshelia – volume: 5 start-page: 90 year: 2011 end-page: 92 ident: b0040 article-title: Inadvertent intrathecal injection of tranexamic acid publication-title: Saudi J Anaesth contributor: fullname: Zaabar – volume: 98 start-page: 270 year: 2003 end-page: 272 ident: b0030 article-title: Convulsions and refractory ventricular fibrillation after intrathecal injection of a massive dose of tranexamic acid publication-title: Anesthesiology contributor: fullname: Mok – volume: 19 start-page: 77 year: 1980 end-page: 84 ident: b0065 article-title: Cerebral complication of antifibrinolytic therapy in the treatment of ruptured intracranial aneurysm. 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of tranexamic acid publication-title: Indian J Anaesth doi: 10.4103/0019-5049.96335 contributor: fullname: Butala – volume: 104 start-page: 241 year: 2007 ident: 10.1016/j.ijoa.2015.11.006_b0045 article-title: Death after an inadvertent intrathecal injection of tranexamic acid publication-title: Anesth Analg doi: 10.1213/01.ane.0000250436.17786.72 contributor: fullname: Garcha – volume: 40 start-page: 1169 year: 2009 ident: 10.1016/j.ijoa.2015.11.006_b0080 article-title: Magnesium sulfate for the treatment of eclampsia: a brief review publication-title: Stroke doi: 10.1161/STROKEAHA.108.527788 contributor: fullname: Euser – volume: 19 start-page: 77 year: 1980 ident: 10.1016/j.ijoa.2015.11.006_b0065 article-title: Cerebral complication of antifibrinolytic therapy in the treatment of ruptured intracranial aneurysm. Animal experiment and a review of literature publication-title: Eur Neurol doi: 10.1159/000115131 contributor: fullname: Yamaura – volume: 114 start-page: 971 year: 2011 ident: 10.1016/j.ijoa.2015.11.006_b0075 article-title: Magnesium-essentials for anesthesiologists publication-title: Anesthesiology doi: 10.1097/ALN.0b013e318210483d contributor: fullname: Herroeder |
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| Snippet | Highlights • Accidental intrathecal injection of tranexamic acid is reported. • Refractory seizures were terminated with magnesium sulfate. • Always verify... •Accidental intrathecal injection of tranexamic acid is reported.•Refractory seizures were terminated with magnesium sulfate.•Always verify medications before... We present a case of accidental injection of tranexamic acid during spinal anesthesia for an elective cesarean delivery. Immediately following intrathecal... |
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| SubjectTerms | Adult Anesthesia & Perioperative Care Anesthesia, Spinal - adverse effects Antifibrinolytic Agents - adverse effects Cesarean Section Female Humans Injections, Spinal Magnesium Magnesium Sulfate - therapeutic use Medication error Medication Errors Obstetrics and Gynecology Receptors, GABA-A - drug effects Spinal anesthesia Status Epilepticus - chemically induced Status Epilepticus - drug therapy Tranexamic acid Tranexamic Acid - adverse effects |
| Title | Refractory status epilepticus after inadvertent intrathecal injection of tranexamic acid treated by magnesium sulfate |
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