Intensive Care Medicine, Hospital of Braga, Braga, Portugal
Intensive Care Medicine, Hospital of Braga, Braga, Portugal.
BMJ Case Rep. 2023 Jul 18;16(7):e251814. doi: 10.1136/bcr-2022-251814.
Several factors have been identified as contributing to medication administration errors, including look-alike, sound-alike (LASA) errors. LASA errors are important causes of serious adverse events arising from spinal injection of tranexamic acid, which can be confused with ampoules of local anaesthesia.We present a case of accidental injection of 250 mg of tranexamic acid rather than prilocaine during spinal anaesthesia. The patient developed lower extremities myoclonus, followed by generalised convulsions and ventricular fibrillation, that was reverted within 6 min. Severe cardiogenic shock requiring both inotropic and vasopressor therapy followed, along with a classic apical ballooning pattern on echocardiography and elevated myocardial injury markers, indicating Takotsubo cardiomyopathy. The patient's condition progressively improved to full recovery, and she was discharged from hospital after 1 month with no neurological deficit or cardiac dysfunction.To our knowledge, this is the 28th reported case of accidental spinal injection of tranexamic acid. We present a brief review of previously published cases.
已经确定了一些导致用药错误的因素，包括形似、音似（LASA）错误。LASA 错误是由于将氨甲环酸误用于椎管内注射而导致严重不良事件的重要原因，这可能与局部麻醉用安瓿瓶混淆。我们报告了一例在脊髓麻醉过程中意外注射 250mg 氨甲环酸而非普鲁卡因的病例。患者出现下肢肌阵挛，随后全身抽搐和心室颤动，6 分钟内得到逆转。随后发生严重的心源性休克，需要使用正性肌力和血管加压药物治疗，心脏超声表现为经典的心尖球囊样改变，心肌损伤标志物升高，提示 Takotsubo 心肌病。患者的病情逐渐好转，完全恢复，1 个月后出院，无神经功能缺损或心功能障碍。据我们所知，这是第 28 例报告的意外椎管内注射氨甲环酸的病例。我们简要回顾了以前发表的病例。
