The Ottawa Hospital, General Campus, Ottawa, ON, Canada.
Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.
Can J Anaesth. 2022 Sep;69(9):1169-1173. doi: 10.1007/s12630-022-02276-3. Epub 2022 Jun 25.
Tranexamic acid administration into the epidural space has not been previously reported. We describe our experience managing and investigating a drug error involving incorrect route of tranexamic acid administration through an epidural catheter.
A syringe containing tranexamic acid, intended for intravenous bolus and infusion intraoperatively using microbore tubing, was inadvertently attached to an epidural catheter via the Luer-type connector on the microbore tubing and epidural adapter.
Saline lavage of the epidural space may be considered if tranexamic acid has been administered into the epidural space. Early multidisciplinary team involvement combined with repeated postevent neurologic monitoring is recommended to guide therapy. Adoption of neuraxial route-specific connectors, when available, may be warranted to reduce Luer-type misconnections.
氨甲环酸注入硬膜外腔尚未有报道。我们描述了我们管理和调查涉及氨甲环酸通过硬膜外导管错误给药途径的药物错误的经验。
含有氨甲环酸的注射器，用于术中通过微管进行静脉推注和滴注，通过微管和硬膜外适配器上的鲁尔型连接器意外地连接到硬膜外导管上。
如果氨甲环酸已注入硬膜外腔，可考虑对硬膜外腔进行盐水灌洗。建议多学科团队早期参与，并结合反复的事件后神经监测，以指导治疗。当有条件时，采用神经轴特定的连接器可能是合理的，以减少鲁尔型误连接。
