What did they find?
This review by Patel, Robertson & McConachie identified 21 published cases of inadvertent spinal TXA administration. Notably 10 patients died, and almost all suffered life-threatening side effects.
What are the common signs?
- Block failure.
- Severe back and buttock pain (universal).
- HT, tachycardia, arrhythmias, CVS collapse.
How should it be managed?
There are three components to managing intrathecal TXA:
- Treating TXA-induced seizures with anticonvulsants: magnesium; benzodiazepines; barbiturates (thiopentone); phenytoin; possibly propofol. Thiopentone infusion was frequently required to terminate seizures.
- Mitigate TXA neurotoxic effects: maintain head-up; CSF lavage to dilute TXA, infusing crystalloid at an interspace higher than an IT needle draining CSF, 10mL for 10mL, repeated up to 4 times.
- Haemodynamic monitoring & support
How does this happen?
In almost all cases ampoule identification error was the primary cause.
Human factor contributions identified were:
- Failure to check ampoule label.
- Similar ampoule appearance.
- Spinal catheter mistaken for IV (1).
- Lack of drug handling and storage policies.
- Storage of tranexamic acid with LA or lack of physical separation.
- Underestimating potential for error.
"All errors could have been prevented..."
A sobering editorial...
- Since 2009 there has been a dramatic increase in reported cases of intrathecal tranexamic acid (TXA), parallel to increasing intraoperative TXA use.
- TXA is powerfully neurotoxic.
- Spinal TXA has a mortality rate > 50%, and high incidence of permanent neurological injury in survivors.
- Almost always results from a drug swap error.
- Because both TXA and bupivacaine are made by many manufacturers, there are many different ampoule designs and drug presentations.
- Risk of harm from TXA error is probably ~ 1 in 10,000 spinals.
- TXA should be physically separated from common spinal drugs and we should consider discarding orphaned ampoules rather than attempting to return to the box.
- Stop and visualise the consequences after your own theoretical spinal drug error: facing the patient, family, colleagues, hospital, regulators...
Randomized Controlled Trial