Department of Anesthesiology and Pain Medicine, St. Vincent Hospital, Catholic University of Korea, Suwon, Korea.
Korean J Anesthesiol. 2011 Apr;60(4):290-3. doi: 10.4097/kjae.2011.60.4.290. Epub 2011 Apr 26.
We present a 32-year-old, extremely obese, pregnant woman who developed severe hypotension and water intoxication after an accidental injection of large bolus of oxytocin during cesarean section under general anesthesia. The patient was initially thought to have an amniotic fluid embolism because of the abrupt hemodynamic changes developed immediately after fetal delivery and lack of recognition of medication error. It is highly recommended that careful attention should be paid not only to the possibility of hemodynamic deterioration and water intoxication if oxytocin is given rapidly in excessive doses, but to the confirmation of the proper use of the drug before it is injected.
我们现介绍一例 32 岁肥胖孕妇，在全麻剖宫产术中意外大剂量静脉推注缩宫素后出现严重低血压和水中毒。由于胎儿娩出后立即出现血流动力学急剧变化且未能识别用药错误，最初考虑为羊水栓塞。强烈建议不仅要注意如果快速给予大剂量缩宫素是否会导致血流动力学恶化和水中毒，还要在注射前确认药物的正确使用。
