Mohseni Kamal, Jafari Alireza, Nobahar Mohammad Rezvan, Arami Ali
Department of Anesthesia, Milad Hospital, Tehran, Iran.
Anesth Analg. 2009 Jun;108(6):1984-6. doi: 10.1213/ane.0b013e3181a04d69.
We present a case of accidental injection of tranexamic acid instead of bupivacaine during spinal anesthesia. One minute after intrathecal injection of 3.5 mL of solution, the patient developed myoclonus of his lower extremities. Accidental intrathecal injection of the wrong drug was suspected and a used ampule of tranexamic acid discovered in the trash can. The ampules of tranexamic acid (500 mg/5 mL) and bupivacaine (5 mg/mL, Merck, Darmstadt, Germany) were similar in appearance. General anesthesia was induced. Ten hours later, the patient developed myoclonus of his upper extremities and face. His polymyoclonus was successfully treated with phenytoin, sodium thiopental infusion, sodium valproate and supportive care of the hemodynamic, and respiratory systems. The patient's condition progressively improved to full recovery.
我们报告一例在脊髓麻醉期间意外将氨甲环酸而非布比卡因注射入鞘内的病例。在鞘内注射3.5 mL溶液一分钟后，患者出现下肢肌阵挛。怀疑意外鞘内注射了错误药物，并在垃圾桶中发现一个用过的氨甲环酸安瓿。氨甲环酸（500 mg/5 mL）和布比卡因（5 mg/mL，德国默克公司，达姆施塔特）的安瓿外观相似。诱导全身麻醉。十小时后，患者出现上肢和面部肌阵挛。其多灶性肌阵挛通过苯妥英钠、硫喷妥钠输注、丙戊酸钠及血流动力学和呼吸系统的支持治疗成功得到控制。患者病情逐渐好转直至完全康复。
