Fatal accident due to the use of intrathecal tranexamic acid. Case report
Keywords:
tranexamic acid, spinal anesthesia, encephalic deathAbstract
Errors in the drugs administration during anesthesia continue to be a major cause of morbidity and mortality, even in industrialized countries. Tranexamic acid is an antifibrinolytic agent indicated to reduce perioperative bleeding in several surgical procedures. The case of a 23-years-old pregnant woman with 32.7 weeks of pregnancy treated at the Baringo Referral Hospital, in Kenya, is presented. During the administration of spinal anesthesia in the cesarean section, this medication was accidentally applied intrathecally. The patient began with myoclonus of the lower limbs, tonic-clonic seizures, and reached cardio-respiratory arrest. She was admitted to Intensive Care, where indirect signs of brain death were identified, and she died on the six day after admission. The literature reports that mortality for this anesthetic accident is very high, due to high concentration of the drug in the cerebrospinal fluid.Downloads
Download data is not yet available.
References
1. Sy Su KMC. Accidental Intrathecal Administration of Tranexamic Acid: A Case Report. J Clin Anesth Pain Manag [Internet]. 2021 [citado 25/05/2022];5(2):232-4. Disponible en: https://scholars.direct/Articles/anesthesia-and-pain-management/jcapm-5-045.php?jid=anesthesia-and-pain-management
2. Elkhateeb R, Kamel HH. Intrathecal Injection of Tranexamic Acid during Caesarean Section: Accidental Fatal Mistake. J Clin Obstet Gynecol Infertil [Internet]. 2017 [citado 25/05/2022];1(3):1014. Disponible en: https://www.remedypublications.com/open-access/intrathecal-injection-of-tranexamic-acid-during-caesarean-section-accidental-fatal-mistake-1166.pdf
3. Sanz Madurga M. Ácido tranexámico: riesgo grave de error de medicación por vía intratecal inadecuada. Panorama Actual Med [Internet]. 2022;46(453):534-5. Disponible en: https://www.farmaceuticos.com/pam/actualidad/farmacovigilancia/acido-tranexamico-riesgo-grave-de-error-de-medicacion-por-via-intratecal-inadecuada/
4. Gupta S, Bhiwal AK, Sharma K. Tranexamic Acid: Beware of Anaesthetic Misadventures. J Obstet Anaesth Crit Care [Internet]. 2018 [citado 25/05/2022];8(1):1-6. Disponible en: https://journals.lww.com/joac/Fulltext/2018/08010/Tranexamic_Acid__Beware_of_Anaesthetic.1.aspx
5. Ayala S. Inyección intratecal inadvertida de ácido tranexámico. Rev Méd Urug [Internet]. 2021 [citado 10/06/2022];37(1):e37108. Disponible en: https://revista.rmu.org.uy/ojsrmu311/index.php/rmu/article/view/681
6. Patel S, Robertson B, McConachie I. Catastrophic drug errors involving tranexamic acid administered during spinal anaesthesia. Anaesthesia. 2019;74(7):904-14. Citado en PubMed; PMID: 30985928.
7. AL-Taei MH, AlAzzawi M, Albustani S, et al. Incorrect Route for Injection: Inadvertent Tranexamic Acid Intrathecal Injection. Cureus [Internet]. 2021 [citado 14/05/2022];13(2):e13055. Disponible en: https://www.cureus.com/articles/50591-incorrect-route-for-injection-inadvertent-tranexamic-acid-intrathecal-injection
8. Wong JO, Yang SF, Tsai MH. Accidental injection of tranexamic acid (Transamin) during spinal anesthesia. Ma Zui Xue Za Zhi. 1988;26(2):249-52. Citado en PubMed; PMID: 3185176.
9. Palanisamy A, Kinsella SM. Spinal tranexamic acid - a new killer in town. Anaesthesia. 2019;74(7):831-3. Citado en PubMed; PMID: 30985919.
10. Shah P, Agrawal P, Nagaria A, et al. Fortuitous intrathecal injection of tranexamic acid. Indian J Anaesth. 2021;65(Suppl 2):S93-S5. Citado en PubMed; PMID: 34188263.
11. Bishop DG, Lundgren AC, Popov I, et al. Intrathecal tranexamic acid during spinal anaesthesia for caesarean delivery: A lethal drug error. S Afr Med J [Internet]. 2019 [citado 14/05/2022];109(11):841-4. Disponible en: https://journals.co.za/doi/abs/10.7196/SAMJ.2019.v109i11.14242
12. Patel S, Loveridge R. Obstetric Neuraxial Drug Administration Errors: A Quantitative and Qualitative Analytical Review. Anesth Analg [Internet]. 2015 [citado 14/05/2022];121(6):1570-7. Disponible en: https://journals.lww.com/anesthesia-analgesia/Fulltext/2015/12000/Obstetric_Neuraxial_Drug_Administration_Errors__A.29.aspx
13. Lecker I, Wang DS, Whissell PD, et al. Tranexamic acid–associated seizures: Causes and treatment. Ann Neurol [Internet]. 2016 [citado 14/05/2022];79(1):18-26. Disponible en: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4738442/
14. Perkins GD, Graesner JT, Semeraro F, et al. European Resuscitation Council Guidelines 2021: executive summary. Resuscitation. 2021;161:1-60. Citado en PubMed; PMID: 33773824.
15. Bustamante Bozzo R, Lacassie Quiroga HJ. Manejo anestésico de la paciente de urgencia embarazada. Rev chil anest [Internet]. 2021 [citado 14/06/2022];50(1):171-95. Disponible en: https://revistachilenadeanestesia.cl/revchilanestv50n01-11/
2. Elkhateeb R, Kamel HH. Intrathecal Injection of Tranexamic Acid during Caesarean Section: Accidental Fatal Mistake. J Clin Obstet Gynecol Infertil [Internet]. 2017 [citado 25/05/2022];1(3):1014. Disponible en: https://www.remedypublications.com/open-access/intrathecal-injection-of-tranexamic-acid-during-caesarean-section-accidental-fatal-mistake-1166.pdf
3. Sanz Madurga M. Ácido tranexámico: riesgo grave de error de medicación por vía intratecal inadecuada. Panorama Actual Med [Internet]. 2022;46(453):534-5. Disponible en: https://www.farmaceuticos.com/pam/actualidad/farmacovigilancia/acido-tranexamico-riesgo-grave-de-error-de-medicacion-por-via-intratecal-inadecuada/
4. Gupta S, Bhiwal AK, Sharma K. Tranexamic Acid: Beware of Anaesthetic Misadventures. J Obstet Anaesth Crit Care [Internet]. 2018 [citado 25/05/2022];8(1):1-6. Disponible en: https://journals.lww.com/joac/Fulltext/2018/08010/Tranexamic_Acid__Beware_of_Anaesthetic.1.aspx
5. Ayala S. Inyección intratecal inadvertida de ácido tranexámico. Rev Méd Urug [Internet]. 2021 [citado 10/06/2022];37(1):e37108. Disponible en: https://revista.rmu.org.uy/ojsrmu311/index.php/rmu/article/view/681
6. Patel S, Robertson B, McConachie I. Catastrophic drug errors involving tranexamic acid administered during spinal anaesthesia. Anaesthesia. 2019;74(7):904-14. Citado en PubMed; PMID: 30985928.
7. AL-Taei MH, AlAzzawi M, Albustani S, et al. Incorrect Route for Injection: Inadvertent Tranexamic Acid Intrathecal Injection. Cureus [Internet]. 2021 [citado 14/05/2022];13(2):e13055. Disponible en: https://www.cureus.com/articles/50591-incorrect-route-for-injection-inadvertent-tranexamic-acid-intrathecal-injection
8. Wong JO, Yang SF, Tsai MH. Accidental injection of tranexamic acid (Transamin) during spinal anesthesia. Ma Zui Xue Za Zhi. 1988;26(2):249-52. Citado en PubMed; PMID: 3185176.
9. Palanisamy A, Kinsella SM. Spinal tranexamic acid - a new killer in town. Anaesthesia. 2019;74(7):831-3. Citado en PubMed; PMID: 30985919.
10. Shah P, Agrawal P, Nagaria A, et al. Fortuitous intrathecal injection of tranexamic acid. Indian J Anaesth. 2021;65(Suppl 2):S93-S5. Citado en PubMed; PMID: 34188263.
11. Bishop DG, Lundgren AC, Popov I, et al. Intrathecal tranexamic acid during spinal anaesthesia for caesarean delivery: A lethal drug error. S Afr Med J [Internet]. 2019 [citado 14/05/2022];109(11):841-4. Disponible en: https://journals.co.za/doi/abs/10.7196/SAMJ.2019.v109i11.14242
12. Patel S, Loveridge R. Obstetric Neuraxial Drug Administration Errors: A Quantitative and Qualitative Analytical Review. Anesth Analg [Internet]. 2015 [citado 14/05/2022];121(6):1570-7. Disponible en: https://journals.lww.com/anesthesia-analgesia/Fulltext/2015/12000/Obstetric_Neuraxial_Drug_Administration_Errors__A.29.aspx
13. Lecker I, Wang DS, Whissell PD, et al. Tranexamic acid–associated seizures: Causes and treatment. Ann Neurol [Internet]. 2016 [citado 14/05/2022];79(1):18-26. Disponible en: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4738442/
14. Perkins GD, Graesner JT, Semeraro F, et al. European Resuscitation Council Guidelines 2021: executive summary. Resuscitation. 2021;161:1-60. Citado en PubMed; PMID: 33773824.
15. Bustamante Bozzo R, Lacassie Quiroga HJ. Manejo anestésico de la paciente de urgencia embarazada. Rev chil anest [Internet]. 2021 [citado 14/06/2022];50(1):171-95. Disponible en: https://revistachilenadeanestesia.cl/revchilanestv50n01-11/
Downloads
Published
2023-09-01
How to Cite
1.
Ojeda-Martell RE, Díaz-Luis O, Álvarez-Valdés MV. Fatal accident due to the use of intrathecal tranexamic acid. Case report. Rev Méd Electrón [Internet]. 2023 Sep. 1 [cited 2025 Apr. 24];45(5):e5128. Available from: https://revmedicaelectronica.sld.cu/index.php/rme/article/view/5128
Issue
Section
Presentation of cases
License
All content published in this journal is Open Access, distributed under the terms of the CC BY-NC 4.0 License.
It allows:
- Copy and redistribute published material in any medium or format.
- Adapt the content.
This will be done under the following terms:
- Attribute the authors' credits and indicate whether changes were made, in which case it must be in a reasonable way.
- Non-commercial use.
- Recognize the journal where it is published.
The copyrights of each article are maintained, without restrictions.
Guidelines to authors
