Article Notes
Article pearls, summaries and comments.
- 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...
- Block failure.
- Severe back and buttock pain (universal).
- Seizures.
- HT, tachycardia, arrhythmias, CVS collapse.
- 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
- 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.
- Similar drug ampoule appearance.
- Drug storage problems.
- Carefully read the ampoule before drawing up, and the syringe label before administering.
- Label syringes!
- Check labels with a second person or a device.
- Use non–luer lock connectors on all neuraxial catheters & devices.
A sobering editorial...
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?
How should it be managed?
There are three components to managing intrathecal TXA:
How does this happen?
In almost all cases ampoule identification error was the primary cause.
Human factor contributions identified were:
"All errors could have been prevented..."
A systematic review of 29 published cases of neuraxial obstetric drug errors, including four maternal deaths related to inadvertent intrathecall tranexamic acid.
What’s the first warning sign of an intrathecal drug error?
Block failure was the most frequent reported complication.