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

Cardiovascular Drug Administration Errors During Neuraxial Anesthesia or Analgesia-A Narrative Review

The prevalence and harm associated with inadvertent neuraxial cardiovascular (CV) medication administration errors are unknown. This review aims to analyze neuraxial CV drug administration errors and associated clinical consequences. The secondary objective is to identify the causes and contributory factors in order to prevent future incidents. The author reviewed reports of accidental administration of CV medications via neuraxial routes during spinal or epidural anesthesia or analgesia published in the last 5 decades (1972-2022). Twenty-seven publications reported neuraxial administration of 10 different CV drugs among patients aged 1 to 81. Seventeen of the 33 errors occurred via the epidural route. Digoxin (9 patients), ephedrine (6), metaraminol (4), labetalol (4), and dopamine (3) were frequently involved in the incidents. Intrathecal digoxin (8 patients) was associated with paraplegia and encephalopathy, of whom 4 pregnant women scheduled for elective cesarean delivery sustained permanent lower limb neurologic deficits. Reversible systemic hemodynamic changes were predominant following the administration of epidural inotropes (dobutamine, dopamine, and epinephrine) and vasopressors (ephedrine and metaraminol). Most administrations (30 out of 32) were only bolus injections. All were preventable skill-based errors. The human factor analysis classification system (HFACS) identified poor organizational climate, inadequate supervision of junior doctors, deficiencies in neuraxial task processes, and incorrect visual perception of objects. The HFACS suggests CV medication safety strategies should include better education and training of junior doctors, modifications in neuraxial anesthesia practices, and careful handling of the CV drug ampoules and syringes.

Neuraxial and peripheral misconnection events leading to wrong-route medication errors: a comprehensive literature review

We conducted a search of the literature to identify case reports of neuraxial and peripheral nervous system misconnection events leading to wrong-route medication errors. This narrative review covers a 20-year period (1999-2019; English-language publications and abstracts) and included the published medical literature (PubMed and Embase) and public access documents. Seventy-two documents representing 133 case studies and 42 unique drugs were determined relevant. The most commonly reported event involved administering an epidural medication by an intravenous line (29.2% of events); a similar proportion of events (27.7%) involved administering an intravenous medication by an epidural line. Medication intended for intravenous administration, but delivered intrathecally, accounted for 25.4% of events. In the most serious cases, outcomes were directly related to the toxicity of the drug that was unintentionally administered. Patient deaths were reported due to the erroneous administration of chemotherapies (n=16), muscle relaxants (n=4), local anesthetics (n=4), opioids (n=1), and antifibrinolytics (n=1). Severe outcomes, including paraplegia, paraparesis, spinal cord injury, and seizures were reported with the following medications: vincristine, gadolinium, diatrizoate meglumine, doxorubicin, mercurochrome, paracetamol, and potassium chloride. These case reports confirm that misconnection events leading to wrong-route errors can occur and may cause serious injury. This comprehensive characterization of events was conducted to better inform clinicians and policymakers, and to describe an emergent strategy designed to mitigate patient risk.

Inadvertent intrathecal injections and best practice management

The intrathecal space has become an important anatomic site for medical intervention not only in anesthesia practice, but also in many other medical specialties. Undesired/inadvertent intrathecal injections (UII) are generally rare. There is tremendous variation in reported inadvertent administrations via an intrathecal route in the literature, mainly as individual cases and very small case-series reports. This review aims to identify potential sources of UII, its clinical presentations, and appropriate management. The inadvertent injectants are classified as anesthetic agents and pain medicines, chemotherapeutics, radiological contrast agents, antibiotics and corticosteroids, and miscellaneous chemical agents such as tranexamic acid. The clinical effects of UII are dependent upon inadvertent injectant(s) and dose being administered intrathecally, and can range from no adverse effect to profound neurological consequences and/or death. Prompt cerebrospinal fluid (CSF) lavage and cardiopulmonary support seem to be the mainstay of treatment. If serious consequences are anticipated, CSF lavage could be lifesaving. This review additionally provides some options for comprehensive management and preventing strategies.

Inadvertent intrathecal injection of labetalol

Labetalol is a combined α and β adrenergic receptor blocker. It is used to treat hypertension, especially in pregnant patients. We report a case of a female patient who was given labetalol intrathecally in place of bupivacaine due to a similar appearance of ampoules which resulted in a drop in blood pressure and pulse rate. The patient responded to fluid resuscitation and there occurred no neurological sequelae.

Accidental intrathecal injection of magnesium sulfate for cesarean section

Magnesium sulfate is used frequently in the operation room and risks of wrong injection should be considered. A woman with history of pseudocholinesterase enzyme deficiency in the previous surgery was referred for cesarean operation. Magnesium sulfate of 700 mg (3.5 ml of 20% solution) was accidentally administered in the subarachnoid space. First, the patient had warm sensation and cutaneous anesthesia, but due to deep tissue pain, general anesthesia was induced by thiopental and atracurium. After the surgery, muscle relaxation and lethargy remained. At 8-10 h later, muscle strength improved and train of four (TOF) reached over 0.85, and then the endotracheal tube was removed. The patient was evaluated during the hospital stay and on the anesthesia clinic. No neurological symptoms, headache or backache were reported. Due to availability of magnesium sulfate, we should be careful for inadvertent intravenous, spinal and epidural injection; therefore before injection must be double checked.

Anesthesia complications in the birthplace: is the neuraxial block always to blame?

This article highlights the common and some of the very serious complications that may occur following neuraxial analgesia for labor and delivery, including headache, backache, infection, hypotension, and hematoma. Total spinal and failed block also are discussed, as are complications unique to epidural anesthesia, such as the intravascular injection of large volumes of local anesthetic (causing seizure or cardiac arrest) and accidental dural puncture.

Immediate management of inadvertent dural puncture during insertion of a labour epidural: a survey of Australian obstetric anaesthetists

Immediate management of inadvertent dural puncture during insertion of an epidural needle during labour is controversial and evidence to guide clinical practice is limited. We surveyed Australian obstetric anaesthetists by anonymous postal questionnaire. Of the 671 surveys sent, 417 (62%) were returned. Following dural puncture, 265 respondents (64%) indicated that they "would usually remove the Tuohy needle and resite". The most common reason for this decision was concern regarding the safety of intrathecal catheters (ITC) (n = 236, 89%), in particular, the risk of misuse (n = 182, 70%). The most frequently reported reason for "usually inserting an ITC" was that this reduced the incidence (n = 120, 84%) and severity (n = 110, 77%) of post dural puncture headache. Increased frequency of ITC insertion was reported by respondents who practised more frequent sessions of obstetric anaesthesia, had fewer years of experience as a consultant anaesthetist and worked in a public hospital. The more widespread use of ITCs seems to be limited by safety concerns.

Accidental intracerebroventricular injection of anaesthetic drugs during induction of general anaesthesia

A 51-year-old patient scheduled for surgery under general anaesthesia was accidentally given remifentanil 150 microg 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.