Accidental Intrathecal Administration of Digoxin in an Elderly Male with End-Stage Renal Disease

Abstract

The systemic effects of digoxin toxicity have been well-known. However, there has been no case citing the effects of intrathecal digoxin in light of end-stage renal disease in the elderly. Here, we report on the case of the successful management of accidental intrathecal digoxin administration in an elderly male with end-stage renal disease.

Inadvertent Intrathecal Administration of Digoxin, with Review of the Literature

“…Binding of digoxin to these isoforms can result in increased intracellular sodium leading to cerebral edema. Of the six prior case reports, four did not document imaging results with MRI sequencing, and it is unknown if cerebral edema was present in those cases [1,2]. Te cases for which intrathecal digoxin was administered without a severe outcome when compared to our patient suggest other factors at play that can place patients at risk for a poor prognosis [1,2].…”

“…In similarly reported cases in the literature, all patients presented with motor and sensory defcits, while some also had an altered level of consciousness and/or diminished brainstem refexes [1][2][3]. In prior cases, the overall prognosis was favorable with the resolution of neurological defcits or residual weakness upon discharge [1][2][3]. Te common strategy in reviewed cases was supportive care until resolution of the symptoms, which ranged from 2 to 7 days [1][2][3].…”

“…In prior cases, the overall prognosis was favorable with the resolution of neurological defcits or residual weakness upon discharge [1][2][3]. Te common strategy in reviewed cases was supportive care until resolution of the symptoms, which ranged from 2 to 7 days [1][2][3]. Table 1 delineates cases with surgical procedures and outcomes; this demonstrates reported cases of intrathecal tranexamic acid, where those related to caesarean birth appeared to have higher mortality, underscoring the hypothesis that pregnancy is a risk factor for adverse outcomes from spinal drug errors.…”

“…One published animal study on rabbits demonstrates spinal blockade via intrathecal administration of digoxin, resulting in cardiopulmonary arrest and death [5]. Of the six similar cases reported, three described spontaneous resolution within 24 hours [1], one case with clinical resolution within two days after administration of high-dose steroids [2], and one case with resolution after one week of intracranial pressure management, IV DIGIFab administration, intra-arterial verapamil delivered, and administration of IV milrinone [3]. One documented case also addressed via intracranial pressure management, IV DIGIFab administration, intra-arterial verapamil, and IV milrinone yet did not result in improvement in lower extremity paraplegia [3].…”

“…Tere are several case reports on neuraxial digoxin administration with spontaneous resolution of sequelae after minimal medical intervention [1,2]. To our knowledge, this is the frst death reported.…”