Inadvertent Intrathecal Injection of Atracurium: A Case Report

Abstract

Drug administration errors are a matter of increasing concern in anesthesiology. Errors usually pertain to the type of drug administered, dosage, rate of administration, or site of administration. A 56-year-old woman weighing 62kg with urinary incontinence was scheduled for a Transobturator Tape (TOT) operation. We decided to perform spinal anesthesia for her operation. We describe the injection of atracurium, a Neuromuscular Blocking (NMB) agent, instead of hyperbaric bupivacaine for spinal anesthesia. The effects of NMB agents in Cerebrospinal Fluid (CSF) are unknown and reports differ, but observations suggest that NMB agents are inert when injected into CSF. Fortunately this patient experienced no adverse effect from this administration error.

Inadvertent Subcutaneous Injection of Atracurium During Circumcision Operation

“…According to the studies, inadvertently intrathecal injection of atracurium causes signs and symptoms such as tachycardia, hypotension, and diplopia (18,19). However, two cases of inadvertently intrathecal injection of atracurium have been reported that did not show hemodynamic symptoms and complications (20,21). According to reports, high-dose intravenous injection of atracurium causes seizure (19).…”