Death After Accidental Injection of Tranexamic Acid During Spinal Anesthesia

트라넥삼산의 척수내 주입으로 인한 사고사

Kim, Min-Jung;Jeong, Su-Jin;Choi, Eun-Seok;Ha, Hong-Il;Lee, Han-Young
김민정;정수진;최은석;하홍일;이한영

  • Published : 20091100

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.

다른 약물을 투여하는 경우, 잘못된 용량의 약물을 투여하는 경우 혹은 잘못된 방법으로 약물을 투여하여 발생하는 의료 사고가 적지 않으며, 이러한 종류의 사고를 줄이고 예방하는 것이 환자와 의료진 모두에게 중요하다. 저자들은 척수마취 과정에서, 사고로 부피바카인 대신 트라넥삼산을 주입하여 사망한 예를 혈액, 뇌척수액과 각 장기별에서의 트라넥삼산 정량검사결과와 함께 보고하고, 이미 보고된 비슷한 유형의 의료사고 5예를 검토 및 고찰하였다.

Keywords

References

  1. 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 https://doi.org/10.1007/s00228-008-0496-4
  2. Slaughter TF, Greenberg CS. Antifibrinolytic drugs and perioperative hemostasis. Am J Hematol 1997;56:32-6 https://doi.org/10.1002/(SICI)1096-8652(199709)56:1<32::AID-AJH7>3.0.CO;2-3
  3. Wong JO, Yang SF, Tsai MH. Accidental injection of tranexamic acid (Transamin) during spinal anesthesia. Ma Zui Xue Za Zhi 1988;26:249-52
  4. de Lede-van der Marrl MG, Hilkens P, Bosch F. The epileptogenic effect of tranexamic acid. J Neurol 1999;246:843 https://doi.org/10.1007/s004150050466
  5. Garcha PS, Mohan CV. Sharma RM. Death after an inadvertent intrathecal injection of tranexamic acid. Anesth Analg, 2007;104:241-2 https://doi.org/10.1213/01.ane.0000250436.17786.72
  6. 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 https://doi.org/10.1097/00000542-200301000-00042
  7. 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 https://doi.org/10.1213/ane.0b013e3181a04d69
  8. 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 https://doi.org/10.1124/jpet.301.1.168
  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