#35955 Inadverted intrathecal injection of atropine and anaphylactic shock

Silvia De Miguel Manso, Rocío Gutiérrez Bustillo, Carlota Gordaliza Pastor, Pilar Olmedo Olmedo
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Abstract

Please confirm that an ethics committee approval has been applied for or granted: Not relevant (see information at the bottom of this page)

Background and Aims

Medication errors are a common source of iatrogenicity. Intrathecal administration of wrong drugs can be life-threatening. A patient suffered an anaphylactic shock after accidental intradural administration of atropine. The aim of this work is to find out if these two facts were related.

Methods

Performing spinal anesthesia for postoperative pain treatment, inadvertent intrathecal inyection of 0.2 mg of atropine instead of morphic chloride occurred to a patient. General anesthesia was induced and then the error was discovered. Surgery was performed without incidents until intravenous administration of metamizole, when severe hypotension underwent. It was resolved with norepinephrine and epinephrine and he recovered without sequelae. Investigating about this episode, authors carried out a bibliographic search in Pubmed, without limiting dates, for studies in which intrathecal administration of atropine was described, in order to find similar cases, consequences and its management.

Results

We found that intrathecal atropine is described by several studies as prevention of postoperative nausea and vomiting after caesarean section with spinal anesthesia. As far as the patient was concern, subsequent allergy testing showed that he was allergic to metamizole, concluding that the episode of hypotension had been consequence of an anaphylactic shock due to this drug, and no related with the medication error.

Conclusions

It has been shown that anticholinergics can be used for prevention of postoperative nausea and vomiting in different routes of administration, including intrathecal route at small doses. Regarding medication errors, a good practice protocol is necessary to avoid serious consequences that, fortunately in this case, did not occur.
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#35955不小心鞘内注射阿托品和过敏性休克
请确认已申请或批准伦理委员会批准:无关(见本页底部信息)背景和目的药物错误是常见的医原性来源。鞘内给药错误可能危及生命。一个病人在意外硬膜内注射阿托品后发生过敏性休克。这项工作的目的是找出这两个事实是否有联系。方法1例患者术后行脊髓麻醉治疗疼痛时,不慎鞘内注射阿托品0.2 mg代替吗啡氯。进行了全身麻醉,然后发现了错误。手术无意外发生,直到静脉注射安硝唑,发生严重低血压。用去甲肾上腺素和肾上腺素治疗后痊愈,无后遗症。为了调查这一事件,作者在Pubmed上进行了文献检索,没有限制日期,为了找到类似的病例,后果和管理,研究中描述了阿托品鞘内给药。结果我们发现鞘内阿托品被一些研究描述为预防脊髓麻醉剖宫产术后恶心和呕吐。就患者而言,随后的过敏试验显示他对metamizole过敏,结论是低血压发作是该药引起的过敏性休克的结果,与用药错误无关。结论抗胆碱能药物可通过不同给药途径预防术后恶心和呕吐,包括小剂量鞘内给药。关于用药错误,一个良好的实践方案是必要的,以避免严重的后果,幸运的是,在这种情况下,没有发生。
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