Inyección intratecal inadvertida de ácido tranexámico / Inadverted intrathecal injection of tranexamic acid / Injeção intratecal inadvertida de ácido tranexâmico

Resumen: Se realiza una revisión descriptiva sobre la inyección de ácido tranexámico en el espacio subaracnoideo. Se destaca que un error puede tener consecuencias catastróficas sobre el paciente, con un alto porcentaje de mortalidad. Se analizan las posibles causas que pueden llevar a la inyección errónea. Se advierte sobre la existencia de preparaciones de ácido tranexámico de similar apariencia a las de la bupivacaína de uso intratecal. Se describe el cuadro clínico de la complicación, el mecanismo de toxicidad, los tratamientos utilizados, y la evolución de los casos relatados en las referencias encontradas. Se discuten estrategias para evitar la complicación, señalando que la seguridad no debe basarse en la perfección humana, sino en medidas que dificulten cometer errores.

Summary: A descriptive review of tranexamic acid injection in the subarachnoid space is performed. A point is made that this error may have catastrophic consequences on the patient with a high percentage of mortality. Possible causes that can lead to an erroneous injection are analyzed. A warning is made about tranexamic acid preparations being similar in appearance to those of bupivacaine for intrathecal use. The study describes the clinical manifestation of this complication, the toxicity mechanism, treatments used, and the evolution of the cases reported in the references found. Strategies to avoid complications are discussed, pointing out that safety should not be based on human perfection, but on measures that make it difficult for humans to make mistakes.

Resumo: Faz-se uma revisão descritiva sobre a injeção de ácido tranexâmico no espaço subaracnóideo. Ressalta-se que é um erro que pode ter consequências catastróficas para o paciente com um elevado percentual de mortalidade. Faz-se uma análise das possíveis causas que podem levar ao uso equivocado de ácido tranexâmico devido a existência de preparações semelhantes em aparência às da bupivacaína para uso intratecal. Descreve-se o quadro clínico da complicação, o mecanismo de toxicidade, os tratamentos utilizados e a evolução dos casos relatados nas referências encontradas. Discute-se estratégias para evitar complicações, ressaltando que a segurança não deve ser baseada na perfeição humana, mas em medidas que dificultem o erro do ser humano.

Inadvertent intrathecal injection of tranexamic acid

Some factors have been identified as contributing to medical errors such as labels, appearance, and location of ampules. In this case report, inadvertent intrathecal injection of 80 mg tranexamic acid was followed by severe pain in the back and the gluteal region, myoclonus on lower extremities and agitation. General anesthesia was induced to complete surgery. At the end of anesthesia, patient developed polymyoclonus and seizures needing supportive care of the hemodynamic, and respiratory systems. He developed ventricular tachycardia treated with Cordarone infusion. The patient's condition progressively improved to full recovery 2 days after. Confusion between hyperbaric bupivacaine and tranexamic acid was due to similarities in appearance between both ampules

Paraspinal Abscess Communicated with Epidural Abscess after Extra-Articular Facet Joint Injection

Facet joint injection is considered to be a safe procedure. There have been some reported cases of facet joint pyogenic infection and also 3 cases of facet joint infection spreading to paraspinal muscle and epidural space due to intra-articular injections. To the author's knowledge, paraspinal and epidural abscesses after facet joint injection without facet joint pyogenic infection have not been reported. Here we report a case in which extra-articular facet joint injection resulted in paraspinal and epidural abscesses without facet joint infection. A 50-year-old man presenting with acute back pain and fever was admitted to the hospital. He had the history of diabetes mellitus and had undergone the extra-articular facet joint injection due to a facet joint syndrome diagnosis at a private clinic 5 days earlier. Physical examination showed tenderness over the paraspinal region. Magnetic resonance image (MRI) demonstrated the paraspinal abscess around the fourth and fifth spinous processes with an additional epidural abscess compressing the thecal sac. The facet joints were preserved. The laboratory results showed a white blood cell count of 14.9x10(9) per liter, an erythrocyte sedimentation rate of 52mm/hour, and 10.88mg/dL of C-reactive protein. Laminectomy and drainage were performed. The pus was found in the paraspinal muscles, which was communicated with the epidural space through a hole in the ligamentum flavum. Cultures grew Staphylococcus aureus. Paraspinal abscess communicated with epidural abscess is a rare complication of extra-articular facet joint injection demonstrating an abscess formation after an invasive procedure near the spine is highly possible.

Intrathecal fentanyl for prevention of shivering in cesarean section.

OBJECTIVES: The aim of this randomized double-blind study was to investigate whether 20 microg of intrathecally administered fentanyl would influence the incidence and severity of shivering in patients undergoing cesarean section. MATERIAL AND METHOD: Sixty healthy patients scheduled for cesarean section under spinal anesthesia using 2.2 ml of 0.5% hyperbaric bupivacaine with 0.2 ml of morphine 0.2 mg, were randomly allocated to receive an additional 0.4 ml of fentanyl 20 mg intrathecally (Group F) or normal saline 0.4 ml (Group S). RESULTS: The incidence of shivering three hours after spinal anesthesia was 6 of 30 patients, 20% in Group F and 15 of 30 patients, 50% in Group S. The difference was statistically significant (p < 0.05). Almost all of the shivering patients started in their first hour after spinal anesthesia (5 patients in Group F and 13 patients in Group S). None in Group F but 4 patients in Group S started shivering before their babies were delivered. The shivering score was also significantly lower in Group F (p < 0.05). Treatment for shivering was requested in 16% and 26% of the shivering patients in Group F and Group S, respectively. There was no difference in the incidence of pharmacologic side effects. The core temperature did not differ significantly between the groups during 3 hours after spinal anesthesia. CONCLUSION: The addition of 20 microg fentanyl in 2.2 ml of 0.5% hyperbaric bupivacaine with 0.2 ml of morphine 0.2 mg intrathecally can reduce the incidence and severity of intraoperative and postoperative shivering after spinal anesthesia for patients who were receiving cesarean section without increasing other side effects.

Perispinal morphine for relief after perianal surgery

Perispinal anesthesia allows injection of epidural [ED] or intrathecal [i.t] morphine to provide long-lasting postoperative analgesia. To compare these two routes, a prospective, randomized study of 40 patients undergoing perianal surgery was performed. Combined spinal-epidural anesthesia with 6 mg of i.t. hyperbaric bupivacaine plus sufentanil 5 micro g and additional ED lidocaine was used. Additionally, each patient received either 2mg [2 ml] of ED morphine plus 1 ml of i.t. normal saline [ED group, n =20] or 0.075 mg [1 ml] of i.t. morphine plus 2 ml of ED normal saline [i.t. group n = 20]. Parentral propacetamol was given for additional postoperative analgesia. No major respiratory depression occurred. Time for first demand of propacetamol was similar in the ED and i.t. groups [250 min]. During the first 24 postoperative hours, VAS pain scores were greater in the i.t. group [p =0.03]. The incidence of side effects such as sedation, pruritis, nausea and vomiting was equal in both groups. The ED protocol was more effective than the i.t. protocol, whilest side-effects were similar

Influencia del tiempo de permanencia sentado en el nivel de anestesia espinal con bupivacaína hiperbárica

Objetivo: Determinar la influencia del tiempo de permanencia de los pacientes en posición sentado en el nivel de bloqueo sensitivo de la anestesia espinal con bupivacaína hiperbárica. Estudio prospectivo experimental tipo ensayo clínico. Hipótesis: El nivel de bloqueo sensitiva que se alcanza con la anestesia espinal se relaciona inversamente con el tiempo de permanencia sentado después de la inyección del anestésico local (bupivacaína hiperbárica al 0.5 por ciento). Metodología: Se incluyeron 91 pacientes distribuidos en cuatro grupos, según el tiempo de permanencia sentado después de inyectado el anestésico, así: cero minutos, 24 pacientes; 3 minutos, 28 pacientes; 6 minutos, 31 pacientes; 9 minutos o más, 8 pacientes. Las variables que podrían haber influido en el nivel sensitivo alcanzado fueron controladas (velocidad de inyección en 15 segundos; dosis, 15 mgr; volumen, 3 cc; espacio, L3-L4; calibre de aguja, No. 26). El nivel de bloqueo sensitivo alcanzado se midió en cada paciente con el método del pinchazo con aguja No. 18. Para el análisis estadístico, que fue realizado con muchas pruebas como chi-cuadrado y coeficiente de correlación de Pearson, se consideró significancia estadística con valores de P<0.05. Resultados y conclusiones: Niveles sensitivos de bloqueo altos (T4 ó más) sólo se alcanzaron en pacientes que se acostaron inmediatamente a los 3 minutos. Ninguno de los pacientes acostados a los 6 minutos o más alcanzó niveles superiores a T4, y el 90 por ciento alcanzó nivel superior a L1. De acuerdo con ésto se puede concluir que el tiempo de permanencia sentado luego de la inyección del anestésico influye en nivel sensitivo alcanzado de manera inversa (a mayor tiempo, menor nivel) y en forma predecible. La importancia de esta predecibilidad está en que estandarizando la técnica anestésica se puede lograr determinando nivel de bloqueo sensitivo, lo que podría traducirse en menores cambios hemodinámicos y respiratorios, evitando así las complicaciones perioperatorias de los niveles de bloqueo altos en cirugías que no lo requieren