Inadvertent intrathecal administration of Tranexamic acid in a case of caesarean section: A report of medication error

Intrathecal Tranexamic acid in caesarean section

Abstract

Medication error is a preventable though not uncommon in anaesthesiology practice with some identifiable contributing factors. Here we are presenting a case of accidental intrathecal administration of Tranexamic acid instead of Bupivacaine heavy during spinal anaesthesia in a parturient. After detecting spinal failure, operation started with re administration of subarachnoid block with Bupivacaine heavy. A live baby was delivered. After 15 min the patient became restless and developed myoclonic seizures of lower extremity followed by generalized convulsion within next 5 minutes. Operation was completed in the meantime. Her convulsion was successfully treated with i.v Midazolam and i.v Phenytoin followed by i.v Thiopentone. She suffered from cardiac arrest which was resuscitated successfully. Later she received Thiopentone infusion along with respiratory and haemodynamic support. Full recovery was there after five days of ICU stay. Early detection and prompt management was the cornerstone for having such a better outcome even without neurodeficit in our case.