Indian Journal of Anaesthesia  
About us | Editorial board | Search | Ahead of print | Current Issue | Past Issues | Instructions
Home | Login  | Users Online: 2443  Print this pageEmail this pageSmall font sizeDefault font sizeIncrease font size    


CASE REPORT
Year : 2012  |  Volume : 56  |  Issue : 2  |  Page : 168-170

Medication error: Subarachnoid injection of tranexamic acid


Department of Anaesthesia and Critical Care, Smt. K. M. Mehta and Smt. G. R. Doshi Institute of Kidney Diseases and Research Center, Dr. H. L. Trivedi Institute of Transplantation Sciences, Civil Hospital Campus, Asarwa, Ahmedabad, Gujarat, India

Correspondence Address:
Bina P Butala
7, Kalamwadi Society, Near Sharda Society, Paldi, Ahmedabad - 380 007, Gujarat
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5049.96335

Rights and Permissions

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.


[FULL TEXT] [PDF]*
Print this article     Email this article
 Next article
 Previous article
 Table of Contents

 Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
 Citation Manager
 Access Statistics
 Reader Comments
 Email Alert *
 Add to My List *
 * Requires registration (Free)
 

 Article Access Statistics
    Viewed4289    
    Printed79    
    Emailed0    
    PDF Downloaded844    
    Comments [Add]    
    Cited by others 12    

Recommend this journal