Patel Santosh
From the Department of Anaesthesia, Tawam Hospital, Al Ain, UAE.
Eur J Anaesthesiol. 2023 May 1;40(5):334-342. doi: 10.1097/EJA.0000000000001812. Epub 2023 Mar 6.
Therapeutic use of tranexamic acid (TXA) to minimise blood loss is common during a wide range of surgical procedures. This review aims to explore the clinical features of the accidental intrathecal administration of TXA and to identify contributory factors that might prevent future incidents. The author searched published reports of accidental intrathecal administration of TXA using Medline and Google Scholar databases from July 2018 to September 2022, including error reports in any language but excluding errors via nonintrathecal routes. The human factors analysis classification system (HFACS) framework was used to examine and classify the human and systemic factors that contributed to the errors. Twenty-two errors of accidental intrathecal administration were reported during the search period. The analysis showed that the outcome was death in eight patients (36%) and permanent harm in four (19%). The fatality rate was higher among female individuals (6/13 versus 2/8 male individuals). Two-thirds of errors (15/22) occurred during orthopaedic surgery (10) and lower segment caesarean sections (5). Nineteen of 21 patients developed refractory or super refractory status epilepticus, requiring mechanical ventilation and intensive care for 3 days to 3 weeks for those who survived the initial few hours. Severe sympathetic stimulation resulting in refractory ventricular arrhythmias was the final event in some patients, with death within a few hours. Lack of familiarity with clinical characteristics caused delayed diagnosis or confusion with other clinical conditions. A proposed plan to manage intrathecal TXA toxicity is presented, including immediate cerebrospinal fluid lavage; however, there is no specific approach. The HFACS suggested mistaking look-alike TXA ampoules for local anaesthetic was the predominant cause. The author concludes that inadvertent intrathecal TXA is associated with mortality or permanent harm in more than 50% of patients. The HFACS demonstrates that all errors are preventable.
在广泛的外科手术中，使用氨甲环酸（TXA）减少失血是常见的治疗方法。本综述旨在探讨TXA意外鞘内注射的临床特征，并确定可能预防未来事件的促成因素。作者使用Medline和谷歌学术数据库搜索了2018年7月至2022年9月期间TXA意外鞘内注射的已发表报告，包括任何语言的错误报告，但不包括非鞘内途径的错误。使用人为因素分析分类系统（HFACS）框架来检查和分类导致错误的人为和系统因素。在搜索期间报告了22例意外鞘内注射错误。分析表明，8名患者（36%）死亡，4名患者（19%）受到永久性伤害。女性个体的死亡率更高（6/13，而男性个体为2/8）。三分之二的错误（15/22）发生在骨科手术（10例）和下段剖宫产（5例）期间。21例患者中有19例出现难治性或超难治性癫痫持续状态，幸存者在最初几个小时存活后需要机械通气和重症监护3天至3周。在一些患者中，严重的交感神经刺激导致难治性室性心律失常是最终事件，数小时内死亡。对临床特征不熟悉导致诊断延迟或与其他临床情况混淆。提出了一项管理鞘内TXA毒性的计划，包括立即进行脑脊液灌洗；然而，没有具体方法。HFACS表明，将外观相似的TXA安瓿误认为局部麻醉剂是主要原因。作者得出结论，超过50%的患者意外鞘内注射TXA会导致死亡或永久性伤害。HFACS表明所有错误都是可以预防的。
