Dr Montosh Kumar Mondal

Assistant professor

Department of Anaesthesia Analgesia and Intensive care medicine

BSMMU

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A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional patient or consumer Such events may be related to professional practice health care products procedures and systems including prescribing order communication product labeling packaging and nomenclature compounding dispensing distribution administration education monitoring And use

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WHAT SORTWHAT SORT

OF ERRORS CAN OCCUR OF ERRORS CAN OCCUR

bullWrong drug

bull patient

bull Wrong route

bull Wrong dose

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Spinal anaesthesia is common and used for many surgical procedure

Accidental administration of wrong drug into the subarachnoid space may be associated with potential hazards

Confidential report in our country observe that accidental administration of wrong drug into the subarachnoid space is responsible for high morbidity and mortality

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Tranexamic acid

Atracurium

Neostigmine

Ephedrine hydrochloride

Magnesium sulphate

Among them tranexamic acid leading to fatal outcome

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Hurry Fatigue Inattention Carelessness Look alike ampoules Lack of double checking false labeling lack of checking before loading performing surgery in emergency setting poor coordination between staff and

Anaesthethesiologist Attendant staff not adequately trained

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Inadvertent intrathecal injection of tranexamic acid

Olfa Kaabachi Mongi Eddhif Karim Rais and Mohamed Ali Zaabar

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In that case report inadvertent intrathecal

injection of 80 mg tranexamic acid was

followed by severe pain in the back and

the gluteal region myoclonus on lower

extremities and agitation General

anesthesia was induced to complete

surgery At the end of anesthesia patient

developed polymyoclonus and seizures

needing supportive care of the

hemodynamic and respiratory systems

He developed ventricular tachycardia

treated with amiodarone infusion

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The patientrsquos condition progressively

improved to full recovery 2 days after

Confusion between hyperbaric

bupivacaine and tranexamic acid was

due to similarities in appearance

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Accidental Intrathecal Injection of Tranexamic Acid in Cesarean Section A Fatal Medication Error

by Firouzeh Veisi MD Babak Salimi MD Gholamreza Mohseni MD Parisa Golfam MD and Azam Kolyaei BS

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Sancheti Institute for Orthopaedics and Rehabilitation Pune India (Garcha)

Department of Anaesthesiology and Critical Care Armed Forces Medical College Pune India

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Year 2012 | Volume 56 | Issue 2 | Page 168170

Medication error Subarachnoid injection of tranexamic acid Bina P Butala Veena R Shah Guruprasad P Bhosale Rajkiran B Shah 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

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Accidental Injection Of Tranexamic Acid Into Subarachnoid Space Leading To Fatal Outcome Case Report And Review

U Srivastava K Joshi V Gupta A Gupta N Chauhan A Dupargude A Saxena A Saxena

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SUMMARY

Anaesthetic accidents are multifactorial and mistakes are not necessarily reversible These errors may be in techniquejudgement or failure of vigilance We report a case of accidental intrathecal administration of large dose (1250 micrograms) of neostigmine methylsulphate in a patient scheduled for repair of inguinal hernia

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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

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In that case the accidental intrathecal injection of tracurium was safe and no analgesia sensory or motor block hemodynamic changes or nerve disturbances were observed for one month

That finding was contrary to several studies which described adverse reactions due to accidental intrathecal injection of neuromuscular blocking drugs

(Acute excitement and seizures caused by introduction of pancuronium and vecuronium into the central nervous system is due to accumulation of cytosolic calcium caused by sustained activation of acetylcholine receptor ion channels

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Accidental intrathecal injection of Ephedrine Hydrochloride was safe and no analgesia sensory or motor block except some increase in blood pressure and pulse rate for short peroid

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Sensory and motor block occurred Patient became unconcious and was shifted to ICU After three days patientrsquos condition was improved and discharged

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A 25years old primi of ASA I with term pregnancy was admitted for elective caesarean section

SAB was given

No sensory or motor block were noted

Suspicion of drug was aroused and a broken ampoule of TXA was found instead of 05 bupivacaine

Again SAB was given with 05 bupivacaine

Operation started

After some times patient complaints severe headache and earache baby delivered patient became gradually restless and developed convulsion

Operation completed patient become more restless drowsy repeated convulsion tachycardia and hypertension( benzodiazepine and pethedine was given) Patient was shifted to ICU

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In ICU patient was semiconsious there was repeated convulsion pulse was 150-160min BP was 170-180110-100 mm Hg

For convulsion inj Midazolam 5 mg inj fosphenytoin 900mg bolus 600mg bolus TPS 50mg 100mg 100mg then TPS 200mghour infusion was started For hypertension and tachycardia inj labetalol and lasix bolus was given

Patient was intubated muscle relaxant was given and put on ventilator

With above treatment patients pulse was around 150min BP-150-14080-70 mm Hg intermittent convulsion when muscle relaxantrsquos action wear off

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Laboratory investigation- selectrolytes glucose calcium creatinine were normal

Saturation of oxygen was gradually declined though patient was on 100 oxygen moderate watery secretion was coming out through ETT

Urine output gradually declined

BP gradually declined

Pulse rate gradually increased

ABG showing pH-72 Pco2-35 mmHg Po2-75 mmHg Hco3-15 BE -15

Inj NaHCo3 was given

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Patient developed high grade temperature

Patient developed VT Hypotension and hypoxia

Patient developed cardiac arrest

CPR given but could not be revived

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TXA is a synthetic analog of the amino acid lysine

bullIt is used to treat or prevent excessive blood loss during

surgery and in various other medical conditions

bull It is an antifibrinolytic that competitively inhibits the

activation of plasminogen to plasmin by binding to specific

sites of both plasminogen and plasmin a molecule

responsible for the degradation of fibrin a protein that forms

the framework of blood clots

bullIts use in humans is generally well tolerated

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Rare in general including gastrointestinal effects dizziness fatigue headache and hypersensitivity reactions

Use of tranexamic acid has a potential risk of thrombosis

Neurotoxicity and seizures have been reported in animal studies

Elevation of systemic and ICP by direct cerebral application in ruptured intracranial aneurysm in animal

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Generalized convulsions

Refractory ventricular tachycardia and fibrilation

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Antagonist action at GABA receptors results in lowering of seizure threshold

Cerebral ischaemia secondary to reduction in regional or global cerebral blood flow

Massive sympathetic discharge leads to hypertension and ventricular arrythymias mostly ventricular fibrillation which are refractory to resuscitation and myoclonus and generalized seizures

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Administration of anticonvulsants

Intensive hemodynamic monitoring

Antiarrhythmic drug

CSF lavage

CSF lavage benefits by removing and diluting the injected drug thus helping in limiting neurological damage

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All accident occurred due to the same appearance of the ampoules

Critical drugs like the drugs used for spinal anaesthesia should have unique appearance and package so posibility of confusion is remote

Anaesthesiologist and nurse must check the ampoule label precisely and stick to the double-checking concept

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Patient Safety Update - The

Royal College of

Anaesthetists

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Safe Anaesthesia Liaison Group PATIENT SAFETY UPDATE June 2012

bull Read the label carefully on the drug ampoule and syringe before drawing up the drug (Labels on ampoules and syringes should be legible) bull The drug drawers and workspace should be organised and tidy similar or

dangerous drugs should be separated or removed if possible bull Labels may be checked by a second person before a drug is drawn up o

administered bull Drug errors should be reported and reviewed bull A pharmacist should be appointed to the operating theatre and changes in

drug presentation notified ahead of time bull Similar packaging and presentation should be avoided where possible bull Drugs should be presented in prefilled syringes where possible bull Drugs should be drawn up and labelled by the anaesthetist who will administer

them bull Drugs should be colour coded by class according to national or international

standards bull Coding by syringe position size or needle on the syringe could be used

Medication Errors

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DrJEdward Johnson

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Safety of the Anaesthetist

Safety of the Surgeon

Safety of the Patient

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THE 5-RrsquoS

World Health Organization WHO Patient Safety Curriculum Guide

bull Right Drug

bull Right Route

bull Right Time

bull Right Dose

bull Right Patient

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Developed by the International Task Force on Anaesthesia Safety

Adopted by the World Federation of Societies of Anaesthesiologists (WFSA)

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All drugs should be clearly labelled

The label on both ampoule and syringe should be read carefully before the drug is drawn up or injected

Ideally drugs should be drawn up and labelled by the anaesthetist who administers them

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