Inyección intratecal inadvertida de ácido tranexámico
Palabras clave:
ÁCIDO TRANEXÁMICO, INYECCIÓN INTRATECAL
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.
Citas
1) Wong J, Yang S, Tsai M. Accidental injection of tranexamic acid (Transamin) during spinal anesthesia. Ma Zui Xue Za Zhi 1988; 26(2):249-52.
2) de Leede-van der Maarl M, Hilkens P, Bosch F. The epileptogenic effect of tranexamic acid. J Neurol 1999; 246(9):843. doi: 10.1007/s004150050466
3) Yeh H, Lau H, Lin P, Sun W, Mok M. Convulsions and refractory ventricular fibrillation after intrathecal injection of a massive dose of tranexamic acid. Anesthesiology. 2003 Jan;98(1):270-2.
4) Garcha P, Mohan C, Sharma R. Death after an inadvertent intrathecal injection of tranexamic acid. Anesth Analg 2007; 104(1):241-2.
5) Mohseni K, Jafari A, Nobahar M, Arami A. Polymyoclonus seizure resulting from accidental injection of tranexamic acid in spinal anesthesia. Anesth Analg 2009; 108(6):1984-6.
6) Sabzi F, Teimouri H, Zokai A. Myoclonus, seizure and ventricular fibrillation afer intrathecal injection of tranexamic acid. J Tehran Univ Heart Center 2009; 4(4):253-5.
7) Kim M, Jeong S, Choi E, Ha H, Lee H. Death after accidental injection of tranexamic acid during spinal anesthesia. Korean J Leg Med 2009; 33(2):139-42.
8) Veisi F, Salimi B, Mohseni G, Golfam P, Kolyaei A. Accidental intrathecal injection of tranexamic acid in cesarean section: A fatal medication error. Apsf 2010; 25(1):9. Disponible en: https://www.apsf.org/article/accidental-intrathecal-injection-of-tranexamic-acid-in-cesarean-section-a-fatal-medication-error/. [Consulta: 25 agosto2015].
9) Kaabachi O, Eddhif M, Rais K, Zaabar M. Inadvertent intrathecal injection of tranexamic acid. Saudi J Anaesth 2011; 5(1):90-2.
10) Srivastava U, Joshi K, Gupta V, Gupta A, Chauhan N, Dupargude A, et al. Accidental injection of tranexamic acid into subarachnoid space leading to fatal outcome: case report and review. Internet J Anesthesiol 2012; 30(2):1-4.
11) Mahmoud K, Ammar A. Accidental intrathecal injection of tranexamic Acid. Case Rep Anesthesiol 2012; 2012:646028. doi: 10.1155/2012/646028
12) Butala B, Shah V, Bhosale G, Shah R. Medication error: Subarachnoid injection of tranexamic acid. Indian J Anaesth 2012; 56(2):168-70.
13) Raghu K, Shrevanni P, Haneef M. Accidental intrathecal injection of tranexamic acid in a term gestation. Int J Neuro Spinal Sci 2013; 1:1-3.
14) Antw-Kusi A, Sam Awortwi W, Serwaa Hemeng A. Unusual complication following spinal anesthesia for caesarean section. Open J Anesthesiol 2013; 3:275-7. doi: 10.4236/ojanes.2013.35060
15) Goyal G, Vajpayee A, Kant R, Singh R. Refractory status epilepticus after accidental intrathecal injection of tranexamic acid. J Acute Med 2014; 4(2):92-4.
16) Roy A, Sarkar S, BasuThakur S, Kr J. Inadvertent intrathecal administration of tranexamic acid in a case of caesarean section: a report of medication error. SEAJCRR 2015; 4:1910-6.
17) Narra GR. Accidental injection of tranexamic acid into intrathecal space. J Res Anaesthesiol Pain Med 2015; 1:12-4.
18) Hatch D, Atito-Narh E, Herschmiller E, Olufolabi A, Owen M. Refractory status epilepticus after inadvertent intrathecal injection of tranexamic acid treated by magnesium sulfate. Int J Obstet Anesth 2016; 26:71-5.
19) Elkhateeb R, Kamel H. Intrathecal injection of tranexamic acid during caesarean section: accidental fatal mistake. J Clin Obstet Gynecol Infertil 2017; 1(3):1014.
20) Grissinger M. Key vulnerabilities in the surgical environment: container mix-ups and syringe swaps. P T 2018; 43(3):129-67.
21) Preferred Physicians Medical Risk Retention Group. Medication Errors: intrathecal injection of tranexamic acid and other mix-ups: defending medication errors litigation. Anesth Law 2017; 44:1-6.
22) Patel S, Robertson B, McConachie I. Catastrophic drug errors involving tranexamic acid administered during spinal anaesthesia. Anaesthesia 2019; 74(7):904-14. doi: 10.1111/anae.14662
23) Rando K, Rey G. Errores de medicamentos LASA en anestesiología en Uruguay. Rev Méd Urug 2017; 33(2):108-25.
24) Ismail S, Taqi A. Medical errors related to look-alike and sound-alike drugs. Anaesth Pain Intensive Care 2013; 17(2):117-22.
25) Nanji K, Patel A, Shaikh S, Seger D, Bates D. Evaluation of perioperative medication errors and adverse drug events. Anesthesiology 2016; 124(1):25-34.
26) WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet 2017; 389(10084):2105-16. doi: 10.1016/S0140-6736(17)30638-4
27) Roberts I, Kawahara T. Proposal for the inclusion of tranexamic acid (anti- fibrinolytic-lysine analogue) in the WHO model list of essential medicines. Geneva: WHO, 2010.
28) Orser B, U D, Cohen M. Perioperative medication errors: building safer systems. Anesthesiology 2016; 124(1):1-3. doi: 10.1097/ALN.0000000000000905
29) Pellegrini A, Giaretta D, Chemello R, Zanotto L, Testa G. Feline generalized epilepsy induced by tranexamic acid (AMCA). Epilepsia 1982; 23(1):35-45.
30) Yamaura A, Nakamura T, Makino H, Hagihara Y. Cerebral complication of antifibrinolytic therapy in the treatment of ruptured intracranial aneurysm. Animal experiment and a review of literature. Eur Neurol 1980; 19(2):77-84.
31) Schlag M, Hopf R, Zifko U, Redl H. Epileptic seizures following cortical application of fibrin sealants containing tranexamic acid in rats. Acta Neurochir (Wien) 2002; 144(1):63-9.
32) Ohashi N, Sasaki M, Ohashi M, Kamiya Y, Baba H, Kohno T. Tranexamic acid evokes pain by modulating neuronal excitability in the spinal dorsal horn. Sci Rep 2015; 5:13458. doi: 10.1038/srep13458
33) Liu H, Tariq R, Liu G, Yan H, Kaye A. Inadvertent intrathecal injections and best practice management. Acta Anaesthesiol Scand 2017; 61(1):11-22. doi: 10.1111/aas.12821
34) Tsui B. Common sense medicine and cerebrospinal lavage. Anaesthesia 2014; 69(8):936-7. doi: 10.1111/anae.12796
35) Worris M. Anesthesia del neuroeje. En: Barash P. Anestesia clínica. 8 ed. Barcelona: Wolters Kluwer, 2017:914-44.
36) Tsui B, Malherbe S, Koller J, Aronyk K. Reversal of an unintentional spinal anesthetic by cerebrospinal lavage. Anesth Analg 2004; 98(2):434-6.
37) Patel S, Loveridge R. obstetric neuraxial drug administration errors: a quantitative and qualitative analytical review. Anesth Analg 2015; 121(6):1570-7.
38) Jain R, Katiyar S. Drug errors in anaesthesiology. Indian J Anaesth 2009; 53(5):539-42.
39) Jensen L, Merry A, Webster C, Weller J, Larsson L. Evidence-based strategies for preventing drug administration errors during anaesthesia. Anaesthesia 2004; 59(5):493-504.
40) Al-Kadhimi S, Patel A, Plaat F. Intrathecal tranexamic acid - an accident waiting to happen? Int J Obstet Anesth 2018; 34:116-7.
41) Litman R. How to prevent medication errors in the operating room? Take away the human factor. Br J Anaesth 2018; 120(3):438-40.
42) Gupta S, Bhiwal A, Sharma K. Tranexamic acid: beware of anaesthetic misadventures. J Obstet Anaesth Crit Care 2018; 8(1):1-6.
2) de Leede-van der Maarl M, Hilkens P, Bosch F. The epileptogenic effect of tranexamic acid. J Neurol 1999; 246(9):843. doi: 10.1007/s004150050466
3) Yeh H, Lau H, Lin P, Sun W, Mok M. Convulsions and refractory ventricular fibrillation after intrathecal injection of a massive dose of tranexamic acid. Anesthesiology. 2003 Jan;98(1):270-2.
4) Garcha P, Mohan C, Sharma R. Death after an inadvertent intrathecal injection of tranexamic acid. Anesth Analg 2007; 104(1):241-2.
5) Mohseni K, Jafari A, Nobahar M, Arami A. Polymyoclonus seizure resulting from accidental injection of tranexamic acid in spinal anesthesia. Anesth Analg 2009; 108(6):1984-6.
6) Sabzi F, Teimouri H, Zokai A. Myoclonus, seizure and ventricular fibrillation afer intrathecal injection of tranexamic acid. J Tehran Univ Heart Center 2009; 4(4):253-5.
7) Kim M, Jeong S, Choi E, Ha H, Lee H. Death after accidental injection of tranexamic acid during spinal anesthesia. Korean J Leg Med 2009; 33(2):139-42.
8) Veisi F, Salimi B, Mohseni G, Golfam P, Kolyaei A. Accidental intrathecal injection of tranexamic acid in cesarean section: A fatal medication error. Apsf 2010; 25(1):9. Disponible en: https://www.apsf.org/article/accidental-intrathecal-injection-of-tranexamic-acid-in-cesarean-section-a-fatal-medication-error/. [Consulta: 25 agosto2015].
9) Kaabachi O, Eddhif M, Rais K, Zaabar M. Inadvertent intrathecal injection of tranexamic acid. Saudi J Anaesth 2011; 5(1):90-2.
10) Srivastava U, Joshi K, Gupta V, Gupta A, Chauhan N, Dupargude A, et al. Accidental injection of tranexamic acid into subarachnoid space leading to fatal outcome: case report and review. Internet J Anesthesiol 2012; 30(2):1-4.
11) Mahmoud K, Ammar A. Accidental intrathecal injection of tranexamic Acid. Case Rep Anesthesiol 2012; 2012:646028. doi: 10.1155/2012/646028
12) Butala B, Shah V, Bhosale G, Shah R. Medication error: Subarachnoid injection of tranexamic acid. Indian J Anaesth 2012; 56(2):168-70.
13) Raghu K, Shrevanni P, Haneef M. Accidental intrathecal injection of tranexamic acid in a term gestation. Int J Neuro Spinal Sci 2013; 1:1-3.
14) Antw-Kusi A, Sam Awortwi W, Serwaa Hemeng A. Unusual complication following spinal anesthesia for caesarean section. Open J Anesthesiol 2013; 3:275-7. doi: 10.4236/ojanes.2013.35060
15) Goyal G, Vajpayee A, Kant R, Singh R. Refractory status epilepticus after accidental intrathecal injection of tranexamic acid. J Acute Med 2014; 4(2):92-4.
16) Roy A, Sarkar S, BasuThakur S, Kr J. Inadvertent intrathecal administration of tranexamic acid in a case of caesarean section: a report of medication error. SEAJCRR 2015; 4:1910-6.
17) Narra GR. Accidental injection of tranexamic acid into intrathecal space. J Res Anaesthesiol Pain Med 2015; 1:12-4.
18) Hatch D, Atito-Narh E, Herschmiller E, Olufolabi A, Owen M. Refractory status epilepticus after inadvertent intrathecal injection of tranexamic acid treated by magnesium sulfate. Int J Obstet Anesth 2016; 26:71-5.
19) Elkhateeb R, Kamel H. Intrathecal injection of tranexamic acid during caesarean section: accidental fatal mistake. J Clin Obstet Gynecol Infertil 2017; 1(3):1014.
20) Grissinger M. Key vulnerabilities in the surgical environment: container mix-ups and syringe swaps. P T 2018; 43(3):129-67.
21) Preferred Physicians Medical Risk Retention Group. Medication Errors: intrathecal injection of tranexamic acid and other mix-ups: defending medication errors litigation. Anesth Law 2017; 44:1-6.
22) Patel S, Robertson B, McConachie I. Catastrophic drug errors involving tranexamic acid administered during spinal anaesthesia. Anaesthesia 2019; 74(7):904-14. doi: 10.1111/anae.14662
23) Rando K, Rey G. Errores de medicamentos LASA en anestesiología en Uruguay. Rev Méd Urug 2017; 33(2):108-25.
24) Ismail S, Taqi A. Medical errors related to look-alike and sound-alike drugs. Anaesth Pain Intensive Care 2013; 17(2):117-22.
25) Nanji K, Patel A, Shaikh S, Seger D, Bates D. Evaluation of perioperative medication errors and adverse drug events. Anesthesiology 2016; 124(1):25-34.
26) WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet 2017; 389(10084):2105-16. doi: 10.1016/S0140-6736(17)30638-4
27) Roberts I, Kawahara T. Proposal for the inclusion of tranexamic acid (anti- fibrinolytic-lysine analogue) in the WHO model list of essential medicines. Geneva: WHO, 2010.
28) Orser B, U D, Cohen M. Perioperative medication errors: building safer systems. Anesthesiology 2016; 124(1):1-3. doi: 10.1097/ALN.0000000000000905
29) Pellegrini A, Giaretta D, Chemello R, Zanotto L, Testa G. Feline generalized epilepsy induced by tranexamic acid (AMCA). Epilepsia 1982; 23(1):35-45.
30) Yamaura A, Nakamura T, Makino H, Hagihara Y. Cerebral complication of antifibrinolytic therapy in the treatment of ruptured intracranial aneurysm. Animal experiment and a review of literature. Eur Neurol 1980; 19(2):77-84.
31) Schlag M, Hopf R, Zifko U, Redl H. Epileptic seizures following cortical application of fibrin sealants containing tranexamic acid in rats. Acta Neurochir (Wien) 2002; 144(1):63-9.
32) Ohashi N, Sasaki M, Ohashi M, Kamiya Y, Baba H, Kohno T. Tranexamic acid evokes pain by modulating neuronal excitability in the spinal dorsal horn. Sci Rep 2015; 5:13458. doi: 10.1038/srep13458
33) Liu H, Tariq R, Liu G, Yan H, Kaye A. Inadvertent intrathecal injections and best practice management. Acta Anaesthesiol Scand 2017; 61(1):11-22. doi: 10.1111/aas.12821
34) Tsui B. Common sense medicine and cerebrospinal lavage. Anaesthesia 2014; 69(8):936-7. doi: 10.1111/anae.12796
35) Worris M. Anesthesia del neuroeje. En: Barash P. Anestesia clínica. 8 ed. Barcelona: Wolters Kluwer, 2017:914-44.
36) Tsui B, Malherbe S, Koller J, Aronyk K. Reversal of an unintentional spinal anesthetic by cerebrospinal lavage. Anesth Analg 2004; 98(2):434-6.
37) Patel S, Loveridge R. obstetric neuraxial drug administration errors: a quantitative and qualitative analytical review. Anesth Analg 2015; 121(6):1570-7.
38) Jain R, Katiyar S. Drug errors in anaesthesiology. Indian J Anaesth 2009; 53(5):539-42.
39) Jensen L, Merry A, Webster C, Weller J, Larsson L. Evidence-based strategies for preventing drug administration errors during anaesthesia. Anaesthesia 2004; 59(5):493-504.
40) Al-Kadhimi S, Patel A, Plaat F. Intrathecal tranexamic acid - an accident waiting to happen? Int J Obstet Anesth 2018; 34:116-7.
41) Litman R. How to prevent medication errors in the operating room? Take away the human factor. Br J Anaesth 2018; 120(3):438-40.
42) Gupta S, Bhiwal A, Sharma K. Tranexamic acid: beware of anaesthetic misadventures. J Obstet Anaesth Crit Care 2018; 8(1):1-6.
Publicado
2021-03-31
Cómo citar
1.
Ayala S. Inyección intratecal inadvertida de ácido tranexámico. Rev. Méd. Urug. [Internet]. 31 de marzo de 2021 [citado 23 de abril de 2024];37(1):e37108. Disponible en: http://www2.rmu.org.uy/ojsrmu311/index.php/rmu/article/view/681
Sección
Trabajos de Revisión o Actualización y Puestas al día
