Christopher L Pysyk1,2, Lucie Filteau3,4. 1. The Ottawa Hospital, General Campus, Ottawa, ON, Canada. cpysyk@toh.ca. 2. Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada. cpysyk@toh.ca. 3. The Ottawa Hospital, General Campus, Ottawa, ON, Canada. 4. Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada.
Abstract
PURPOSE: Tranexamic acid administration into the epidural space has not been previously reported. We describe our experience managing and investigating a drug error involving incorrect route of tranexamic acid administration through an epidural catheter. CLINICAL FEATURES: A syringe containing tranexamic acid, intended for intravenous bolus and infusion intraoperatively using microbore tubing, was inadvertently attached to an epidural catheter via the Luer-type connector on the microbore tubing and epidural adapter. CONCLUSIONS: Saline lavage of the epidural space may be considered if tranexamic acid has been administered into the epidural space. Early multidisciplinary team involvement combined with repeated postevent neurologic monitoring is recommended to guide therapy. Adoption of neuraxial route-specific connectors, when available, may be warranted to reduce Luer-type misconnections.
PURPOSE: Tranexamic acid administration into the epidural space has not been previously reported. We describe our experience managing and investigating a drug error involving incorrect route of tranexamic acid administration through an epidural catheter. CLINICAL FEATURES: A syringe containing tranexamic acid, intended for intravenous bolus and infusion intraoperatively using microbore tubing, was inadvertently attached to an epidural catheter via the Luer-type connector on the microbore tubing and epidural adapter. CONCLUSIONS: Saline lavage of the epidural space may be considered if tranexamic acid has been administered into the epidural space. Early multidisciplinary team involvement combined with repeated postevent neurologic monitoring is recommended to guide therapy. Adoption of neuraxial route-specific connectors, when available, may be warranted to reduce Luer-type misconnections.