Intrathecal tranexamic acid during spinal anaesthesia for caesarean delivery: A lethal drug error

Roux

2022

S Afr Fam Pract

Obstetric spinal anaesthesia is routinely used in South African district hospitals for caesarean sections, providing better maternal and neonatal outcomes than general anaesthesia in appropriate patients. However, practitioners providing anaesthesia in this context are usually generalists who practise anaesthesia infrequently and may be unfamiliar with dealing with complications of spinal anaesthesia or with conversion from spinal to general anaesthesia. This is compounded by challenges with infrastructure, shortages of equipment and sundries and a lack of context-sensitive guidelines and support from specialised anaesthetic services for district hospitals. This continuous professional development (CPD) article aims to provide guidance with respect to several key areas related to obstetric spinal anaesthesia, and to address common concerns and queries. We stress that good clinical practice is essential to avoid predictable, common complications, and hence a thorough preoperative preparation is essential. We further discuss clinical indications for preoperative blood testing, spinal needle choice, the use of isobaric bupivacaine, spinal hypotension, failed or partial spinal block and pain during the caesarean section. Where possible, relevant local and international guidelines are referenced for further reading and guidance, and a link to a presentation of this topic is provided.

Section: Good Basic Practice Is Key To Avoiding Complicationsmentioning

confidence: 99%

“…6 In parallel to its increased use, there has been an increase in inadvertent intrathecal administration of this agent. 7,8 This is possibly linked to its similarity in appearance to bupivacaine and storage in close proximity to bupivacaine, either on the spinal trolley or on the anaesthetic drug trolley. This catastrophic drug error is often Obstetric spinal anaesthesia is routinely used in South African district hospitals for caesarean sections, providing better maternal and neonatal outcomes than general anaesthesia in appropriate patients.…”

Section: Good Basic Practice Is Key To Avoiding Complicationsmentioning

confidence: 99%

Troubleshooting obstetric spinal anaesthesia at district hospital level

Roux

2022

S Afr Fam Pract

“…This potential drug error was highlighted, and recommendations to prevent it outlined in a 2019 publication following the identification of a fatal case through a South African confidential inquiry into maternal deaths. 7 The authors are aware of 3 cases that occurred in South Africa during December 2021 and January 2022, raising concern that the problem may be more widespread than published case reports would suggest. Two were fatal, and one associated with prolonged ventilation and neurologic injury.…”

mentioning

confidence: 99%

Tranexamic acid at cesarean delivery: drug‐error deaths

Moran

Fawcus

et al. 2022

BJOG

The use of tranexamic acid for postpartum hemorrhage has entered obstetrical practice globally with the evidence‐based expectation of saving lives. This improvement in the care of women with postpartum hemorrhage has come at a price. For the anesthetist, having tranexamic acid ampoules close at hand would seem an obvious strategy to facilitate its use during cesarean delivery, an important setting for severe hemorrhage. Tragically, we have identified a number of recent instances of inadvertent intrathecal administration of tranexamic acid instead of local anesthetic for spinal anesthesia. Reported cases of this catastrophic error seem to be increasing. The profound neurotoxicity of tranexamic acid causes rapid‐onset convulsions, with mortality of 50%. How can these tragic errors be averted? Drug safety alerts have been issued by the US Food and Drug Administration and the World Health Organization, but that is not enough. We recommend extensive dissemination of information to raise awareness of this potential hazard, and local hospital protocols to ensure that tranexamic acid is stored separately from anesthetic drugs, preferably outside the operating room and with an auxiliary warning label. Implementation of safety strategies on a very large scale will be needed to ensure that the life‐saving potential of tranexamic acid is not eclipsed by drug‐error mortality.

“…This potential drug error was highlighted, and recommendations to prevent it outlined in a 2019 publication following the identification of a fatal case through a South African confidential inquiry into maternal deaths. 7 The authors are aware of three cases that occurred in South Africa during December 2021 and January 2022, raising concern that the problem may be more widespread than published case reports would suggest. Two were fatal, and one associated with prolonged ventilation and neurologic injury.…”

mentioning

confidence: 99%

Tranexamic acid at cesarean delivery: Drug‐error deaths

Moran

Intl J Gynecology & Obste

Fawcus

et al. 2022

The use of tranexamic acid for postpartum hemorrhage has entered obstetrical practice globally with the evidence-based expectation of saving lives. This improvement in the care of women with postpartum hemorrhage has come at a price. For the anesthetist, having tranexamic acid ampoules close at hand would seem an obvious strategy to facilitate its use during cesarean delivery, an important setting for severe hemorrhage. Tragically, we have identified a number of recent instances of inadvertent intrathecal administration of tranexamic acid instead of local anesthetic for spinal anesthesia. Reported cases of this catastrophic error seem to be increasing. The profound neurotoxicity of tranexamic acid causes rapid-onset convulsions, with mortality of 50%. How can these tragic errors be averted? Drug safety alerts have been issued by the US Food and Drug Administration and the World Health Organization, but that is not enough. We recommend extensive dissemination of information to raise awareness of this potential hazard, and local hospital protocols to ensure that tranexamic acid is stored separately from anesthetic drugs, preferably outside the operating room and with an auxiliary warning label. Implementation of safety strategies on a very large scale will be needed to ensure that the life-saving potential of tranexamic acid is not eclipsed by drug-error mortality.