Fortuitous intrathecal injection of tranexamic acid

Shah, Pratibha Jain; Agrawal, Pratiksha; Nagaria, Anisha; Habeeba, K P Ummu

doi:10.4103/ija.ija_1586_20

Cited by 6 publications

(20 citation statements)

References 7 publications

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“…The search flowchart (Supplementary File 1, http://links.lww.com/EJA/A805) shows 16 (of 18) reports of intrathecal TXA errors containing 22 (of 28) patients for inclusion in the analysis 11–26 Table 1. and Supplementary File 2, http://links.lww.com/EJA/A806 summarise personal details, the dose administered, clinical course, consequences and outcome.…”

Section: Resultsmentioning

confidence: 99%

“…and Supplementary File 2, http://links.lww.com/EJA/A806 summarise personal details, the dose administered, clinical course, consequences and outcome. More than two-thirds of errors (15 of 22) occurred in patients scheduled for orthopaedic 11–13,16–18,20,22,23 and lower segment caesarean section procedures 15,17,21,24,25 …”

Section: Resultsmentioning

confidence: 99%

“…Other recurrent issues include suboptimal storage and handling of TXA ampoules and deficiencies in spinal anaesthesia task processes. One hospital reported either four 14 or two errors of accidental intrathecal TXA administration 12,17,18,22 . The errors recurred on the same day 22 or the next day 12 on two occasions.…”

Section: Resultsmentioning

confidence: 99%

“…None of the reported patient's serum or cerebrospinal fluid (CSF) TXA levels were measured. Electroencephalographic monitoring (EEG), 13,16,17,20,21 MRI, 16,20,21,25 CSF analysis 19,24 and electromyography 20 were reported in some patients. MRI did not reveal any significant abnormality in the three patients.…”

Section: Resultsmentioning

confidence: 99%

“…27 Gender, surgery and dose dilemmas The cumulative (current and previous 10 ) analysis revealed a substantially increased risk for death or permanent harm in women compared with men. Of 27 women known to be Male: 8, 11,12,16,[17][18][19][20] Female: 13, 12-15,17,21,23 -26 Unknown: 1 22 Male: 7, Female: 14 Surgery Orthopaedic: 10 [11][12][13][16][17][18]20,22,23 Obstetric (LSCS): 5 15,17,21,24,25 (4 elective,1 emergency) gynaec: 5 12,14,26 General surgery: 2 14,19 Orthopaedic: 6 Obstetric (LSCS): 7 (all electives), Urology: 3, General surgery: 4 Dose (mg) 100 to <200: 1 15 200 to 250: 8 11,14,17,18,19,21,23,24 300 to 350: 5 14,19,20 400 mg: 1 26 Unknown: 7 12,13,16,18,22,25 <100: 3 <200: 1). Combined...…”

Section: Discussionmentioning

confidence: 99%

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Tranexamic acid-associated intrathecal toxicity during spinal anaesthesia

Patel

2023

European Journal of Anaesthesiology

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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.

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Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Tranexamic acid-associated intrathecal toxicity during spinal anaesthesia

Patel

2023

European Journal of Anaesthesiology

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On Patient Safety: Concerns About Topical Tranexamic Acid in Spine Surgery

Zhang

et al. 2022

Clin Orthop Relat Res

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The goal of "On Patient Safety" column is to highlight key safety messages about clinically relevant topics. In this month's guest column, Dr. Tian-qing Li and colleagues discuss the safety issues related to the off-label use of topical tranexamic acid (TXA) in spine surgery. TXA is an antifibrinolytic agent that is widely used around the world to reduce blood loss in joint replacement; its use has recently increased in spine surgery for the same indication. Their column highlights the safety concerns associated with the off-label use of any potent therapeutic agent; however, these concerns are heightened in this case by the serious risk of inadvertent intrathecal administration of TXA resulting from an intraoperative dural tear or other complication, which can lead to a truly catastrophic result.Their essay spotlights several components needed for the safe use of offlabel drugs and medical devices. The authors discuss the increased need for appropriate informed consent for our patients whenever we use TXA off-label, and they also note serious knowledge gaps among surgeons who routinely use this product off-label. Additionally, the authors highlight the need for appropriate studies to confirm the safety profile of off-label uses of TXA.Many surgeons use drugs and devices off-label in ways that are safe. Addressing the concerns pointed out by Dr. Li and colleagues in off-label usage of TXA will increase patient safety for this drug, and doing so points the way for safer administration of other off-label therapeutics.

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Polymyoclonus, ventricular fibrillation and Takotsubo after accidental spinal injection of tranexamic acid

Costa

Martins

et al. 2023

BMJ Case Rep

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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.

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Fortuitous intrathecal injection of tranexamic acid

Cited by 6 publications

References 7 publications

Tranexamic acid-associated intrathecal toxicity during spinal anaesthesia

Tranexamic acid-associated intrathecal toxicity during spinal anaesthesia

On Patient Safety: Concerns About Topical Tranexamic Acid in Spine Surgery

Polymyoclonus, ventricular fibrillation and Takotsubo after accidental spinal injection of tranexamic acid

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