Accidental intrathecal administration of dopamine in spinal anaesthesia for caesarean section: A case report
Inadvertent intrathecal administration of a wrong drug can be a catastrophic event. We are reporting a case of 24 year old female patient who underwent elective caesarean section for oligohydramnios. During subarachnoid block resident doctor wrongly loaded 2 ml of Dopamine hydrochloride (80 mg) in t...
| Main Authors: | , , , |
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| Format: | Article |
| Language: | English |
| Published: |
Taylor & Francis Group
2017-04-01
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| Series: | Egyptian Journal of Anaesthesia |
| Subjects: | |
| Online Access: | http://www.sciencedirect.com/science/article/pii/S1110184916300769 |
| _version_ | 1818971038530142208 |
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| author | Udita Naithani Devendra Verma Abhilasha Thanvi Rekha Bayer |
| author_facet | Udita Naithani Devendra Verma Abhilasha Thanvi Rekha Bayer |
| author_sort | Udita Naithani |
| collection | DOAJ |
| description | Inadvertent intrathecal administration of a wrong drug can be a catastrophic event.
We are reporting a case of 24 year old female patient who underwent elective caesarean section for oligohydramnios. During subarachnoid block resident doctor wrongly loaded 2 ml of Dopamine hydrochloride (80 mg) in the syringe assuming it to be 0.5% hyperbaric bupivacaine and injected it intrathecally. After 5 min there was no sensory-motor blockade and the senior anaesthesiologist identified the mistake that dopamine had been administered in place of bupivacaine. Immediately general anaesthesia was induced and a healthy, male baby was delivered. Cardiovascular changes in the form of hypertension, tachycardia, extrasystoles and irregular rhythm did occur but were promptly treated. No neurological complications occurred, the patient was successfully extubated and discharged on the 7th postoperative day uneventfully.
We conclude that before administration, drug labels should be carefully read to avoid medication errors from lookalike ampoules. |
| first_indexed | 2024-12-20T14:46:01Z |
| format | Article |
| id | doaj.art-b79ced85e0264b9c9cc17aae00105383 |
| institution | Directory Open Access Journal |
| issn | 1110-1849 |
| language | English |
| last_indexed | 2024-12-20T14:46:01Z |
| publishDate | 2017-04-01 |
| publisher | Taylor & Francis Group |
| record_format | Article |
| series | Egyptian Journal of Anaesthesia |
| spelling | doaj.art-b79ced85e0264b9c9cc17aae001053832022-12-21T19:37:08ZengTaylor & Francis GroupEgyptian Journal of Anaesthesia1110-18492017-04-0133220520710.1016/j.egja.2016.08.011Accidental intrathecal administration of dopamine in spinal anaesthesia for caesarean section: A case reportUdita NaithaniDevendra VermaAbhilasha ThanviRekha BayerInadvertent intrathecal administration of a wrong drug can be a catastrophic event. We are reporting a case of 24 year old female patient who underwent elective caesarean section for oligohydramnios. During subarachnoid block resident doctor wrongly loaded 2 ml of Dopamine hydrochloride (80 mg) in the syringe assuming it to be 0.5% hyperbaric bupivacaine and injected it intrathecally. After 5 min there was no sensory-motor blockade and the senior anaesthesiologist identified the mistake that dopamine had been administered in place of bupivacaine. Immediately general anaesthesia was induced and a healthy, male baby was delivered. Cardiovascular changes in the form of hypertension, tachycardia, extrasystoles and irregular rhythm did occur but were promptly treated. No neurological complications occurred, the patient was successfully extubated and discharged on the 7th postoperative day uneventfully. We conclude that before administration, drug labels should be carefully read to avoid medication errors from lookalike ampoules.http://www.sciencedirect.com/science/article/pii/S1110184916300769Medication errorIntrathecal dopamineSpinal anaesthesiaAccidental intrathecal administration |
| spellingShingle | Udita Naithani Devendra Verma Abhilasha Thanvi Rekha Bayer Accidental intrathecal administration of dopamine in spinal anaesthesia for caesarean section: A case report Egyptian Journal of Anaesthesia Medication error Intrathecal dopamine Spinal anaesthesia Accidental intrathecal administration |
| title | Accidental intrathecal administration of dopamine in spinal anaesthesia for caesarean section: A case report |
| title_full | Accidental intrathecal administration of dopamine in spinal anaesthesia for caesarean section: A case report |
| title_fullStr | Accidental intrathecal administration of dopamine in spinal anaesthesia for caesarean section: A case report |
| title_full_unstemmed | Accidental intrathecal administration of dopamine in spinal anaesthesia for caesarean section: A case report |
| title_short | Accidental intrathecal administration of dopamine in spinal anaesthesia for caesarean section: A case report |
| title_sort | accidental intrathecal administration of dopamine in spinal anaesthesia for caesarean section a case report |
| topic | Medication error Intrathecal dopamine Spinal anaesthesia Accidental intrathecal administration |
| url | http://www.sciencedirect.com/science/article/pii/S1110184916300769 |
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