Browse > Article

Death After Accidental Injection of Tranexamic Acid During Spinal Anesthesia  

Kim, Min-Jung (Division of Forensic Medicine, National Institute of Scientific Investigation)
Jeong, Su-Jin (Division of Forensic Toxicology, National Institute of Scientific Investigation)
Choi, Eun-Seok (Seventh Special Force Brigade)
Ha, Hong-Il (Division of Forensic Medicine, National Institute of Scientific Investigation)
Lee, Han-Young (Western District Office, National Institute of Scientific Investigation)
Publication Information
The Korean Journal of Legal Medicine / v.33, no.2, 2009 , pp. 139-142 More about this Journal
Abstract
Medication errors such as administration of wrong drugs, wrong dosage and erroneous route of administration are not rare among medical misadventures. We present an autopsy case of accidental injection of tranexamic acid instead of bupivacaine during spinal anesthesia, accompanying the quantitative result of the tranexamic acid in the blood, cerebrospinal fluid and each internal organs. We think that warning signs on syringes and ampoules, simple and unified guideline for drug administration, separative documentation of drug administration and interpersonal communication on drug information should be done to prevent this type of medical errors.
Keywords
accidental injection; tranexamic acid; spinal anesthesia; medical misadventure;
Citations & Related Records
연도 인용수 순위
  • Reference
1 Slaughter TF, Greenberg CS. Antifibrinolytic drugs and perioperative hemostasis. Am J Hematol 1997;56:32-6   DOI   PUBMED   ScienceOn
2 de Lede-van der Marrl MG, Hilkens P, Bosch F. The epileptogenic effect of tranexamic acid. J Neurol 1999;246:843   DOI   PUBMED   ScienceOn
3 Mohseni K, Jafari A, Nobahar MR, Arami A. Polymyoclonus seizure resulting from accidental injection of tranexamic acid in spinal anesthesia. Anesth Analg 2009;108:1984-6   DOI   PUBMED   ScienceOn
4 Kuitunen T, Kuisma P, Hoppu K. Medication errors made by health care professionals. Analysis of the Finnish Poison Information Centre data between 2000 and 2007. Eur J Clin Pharmacol 2008;64:769-74   DOI   ScienceOn
5 Garcha PS, Mohan CV. Sharma RM. Death after an inadvertent intrathecal injection of tranexamic acid. Anesth Analg, 2007;104:241-2   DOI   PUBMED   ScienceOn
6 Wong JO, Yang SF, Tsai MH. Accidental injection of tranexamic acid (Transamin) during spinal anesthesia. Ma Zui Xue Za Zhi 1988;26:249-52   PUBMED
7 Furtm$\ddot{u}$ller R, Schlag MG, Verger M, et al. Tranexamic acid, a widely used antifibrinolytic agent, causes convulsions by a gamma-aminobutyric acid(A) receptor antagonistic effect. J Pharmacol Exp Ther 2002;301:168-73   DOI   PUBMED   ScienceOn
8 Yeh HM. Lau HP, Lin PL, Sun WZ, Mok MS. Convulsions and refractory ventricular fibrillation after intrathecal injection of a massive dose of tranexamic acid. Anesthesiology 2003;98:270-2   DOI   PUBMED   ScienceOn
9 Lee BW, Kim YS, Kwon TJ, Chung NE, Choi YS, Lee WT. A death resulting from inadvertent intravenous injection of antidiarrheal. Kor J Leg Med 2004;28:68-71