Inadvertent intrathecal injection of labetalol in a patient undergoing post-partum tubal ligation

Balestrieri, Philip J.; Hamza, M.S.; Ting, Paul H.; Blank, Randal S.; Grubb, Chris

doi:10.1016/j.ijoa.2005.02.005

Cited by 16 publications

(10 citation statements)

References 14 publications

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“…While the injection of the wrong drug into a correctly identified intravenous lines is given much attention in the literature [3], the injection of the right medication into a wrongly identified, usually arterial, line occurs much less frequently [4]. The literature contains only rare accounts of drugs being accidentally administered via the epidural or intrathecal route in the course of anaesthesia [5, 6]. Intracerebroventricular injection of propofol or remifentanil has not yet been reported, and the literature contains only one report of a near mishap in which the intracerebroventricular administration of propofol was prevented at the last minute [7].…”

Section: Discussionmentioning

confidence: 99%

Accidental intracerebroventricular injection of anaesthetic drugs during induction of general anaesthesia

et al. 2006

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SummaryA 51-year-old patient scheduled for surgery under general anaesthesia was accidentally given remifentanil 150 lg and propofol 1% 10 ml through an intracerebroventricular totally implantable access port placed in the right infraclavicular region, which was mistakenly thought to be an intravenous line. Severe pain in the head and neck caused the mistake to be discovered rapidly, and 20 ml of a mixture of cerebrospinal fluid and the anaesthetic drugs were aspirated from the implantable access port. The patient suffered no apparent adverse neurological sequelae. Subcutaneous implantation of totally implantable access ports (TIAPs) is now common in a number of clinical disciplines [1]. In patients with an implanted TIAP, general anaesthesia is usually induced via this infusion system to spare the patient additional venepuncture. We report the accidental injection of anaesthetic drugs through an intracerebroventricular TIAP during the attempted induction of general anaesthesia. Case reportA 51-year-old man suffering from a therapy-resistant pain syndrome with neuropathic pain in the right arm following trauma was brought to the operating theatre for implantation of an intrathecal infusion system. For scheduling reasons, the operating theatre and the anaesthetic team were changed at short notice. On arrival in the theatre, the patient was not fully alert and was receiving a morphine infusion through a TIAP implanted in his right infraclavicular region. A chest X-ray showed a TIAP (Port-A-Cath II, SIMS Deltec, St Paul, MN) implanted in the infraclavicular region with the catheter ascending towards the area of the right internal jugular vein (Fig. 1).A normal saline infusion was connected to the TIAP before induction of general anaesthesia, and standard monitoring was attached (ECG, pulse oximetry and automated non-invasive blood pressure). An infusion of remifentanil at a rate of 0.6 lg.kg )1 .min )1 was started by a trainee anaesthetist via the TIAP. Simultaneously, the patient was pre-oxygenated for 3 min, during which he appeared to become more sedated. Propofol 1% 10 ml were then injected. Seconds later, the patient complained of severe neck pain. The consultant anaesthetist was immediately called by the trainee anaesthetist; he quickly diagnosed the mishap. To minimise the possible toxic effect of the drugs, he attempted to withdraw the contaminated cerebrospinal fluid and aspirated approximately 20 ml of a mixture of propofol, remifentanil and cerebrospinal fluid. The patient's neck pain disappeared, but he remained sedated, so mask ventilation was continued, a peripheral venous line was inserted and the decision was made to induce general anaesthesia to secure the airway and prevent possible complications such as respiratory depression and convulsions. The planned intrathecal pump implantation was performed without complication, and the patient's trachea was extubated immediately after surgery. Postoperative neurological recovery was uneventful and cerebrospinal fluid examination on the next day revealed n...

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Section: Discussionmentioning

confidence: 99%

Accidental intracerebroventricular injection of anaesthetic drugs during induction of general anaesthesia

et al. 2006

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“…We appreciate Dr. Lee's concern regarding the choice of words in our case report 1 and are painfully conscious of the current malpractice crisis affecting medicine. His concern that a plaintiff's attorney may "bite us" by citing the dictionary definition of "inadvertent" 2 suffers from several misunderstandings, however.…”

Section: In Replymentioning

confidence: 96%

“…Hypotension and intraoperative nausea and vomiting during regional anesthesia for cesarean section I was interested to read the review article by Balki and Carvalho about intraoperative nausea and vomiting (IONV) during regional anesthesia for cesarean section. 1 However, in the section about hypotension as a cause of IONV, there is an error in the data presented in Table 2. The table quotes the target blood pressures in the studies referred to.…”

Section: In Replymentioning

confidence: 99%

In Reply

Balestrieri

2006

International Journal of Obstetric Anesthesia

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“…Drug administration errors include neuraxial administration of almost every neuromuscular-blocking drug: succinylcholine, 3 rocuronium, 4 cisatracurium, 5 atracurium, 6 vecuronium, 7 and pancuronium 8 ; general anesthetics, including thiopental, 9,10 methohexital, 11 diazepam, 12 and midazolam 13 ; vasopressor agents, including ephedrine 14,15 and metaraminol 16 ; antiemetics, including ondansetron 17 ; and a host of other agents such as potassium chloride, 18,19 antibiotics, 20 magnesium sulfate, 21 glucose, 22 total parenteral nutrition, 23 and labetalol. 24 It seems that if the drug is within arm's reach of the anesthesiologist, we have managed to unwittingly inject it into the neuraxis. Even ether 25 and paraldehyde 26 have been injected epidurally.…”

Section: Everything!mentioning

confidence: 99%

“…24 Last year, there were reports in the literature involving intrathecal injection of IV magnesium. 27 In 2012, it was chlorhexidine, 28 which tragically resulted in both horrific outcome (paraplegia) and very negative press coverage.…”

Section: Hardlymentioning

confidence: 99%