Zirak Nahid, Soltani Ghasem, Ghomian Naiere, Hasanpour Mohamad Reza, Mashayekhi Zahra
Department of Anesthesiology, Imam Reza Hospital, Faculty of Medicine, Mashhad University of Medical Sciences (MUMS), Mashhad, Iran.
Saudi J Anaesth. 2011 Apr;5(2):223-5. doi: 10.4103/1658-354X.82811.
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. This finding was contrary to several studies, which described adverse reactions due to accidental intrathecal injection of neuromuscular blocking drugs.
本报告讲述了在脊髓麻醉期间，一名38岁计划接受腹部子宫切除术的女性被误将阿曲库铵鞘内注射的经过。当未观察到镇痛效果时，才意识到注射有误。术后通过四个成串刺激比值对她进行评估，分别在术后1小时、2小时、24小时、48小时，然后在1周和2周时测量她的呼吸频率、睁眼及伸舌情况，最后在下个月进行最终评估。该患者在手术期间和术后各阶段时间正常，在第一个月内未观察到异常发现。这一发现与多项研究相反，那些研究描述了因意外鞘内注射神经肌肉阻滞药物而产生的不良反应。
