Accidental intra-thecal tranexamic acid injection during spinal anesthesia for myomectomy: Case report and review

INTRODUCTION: Inadvertent drug administration stays one of the reasons for avoidable morbidity and mortality complications around the globe. This report will talk about a case of inadvertent Intra-thecal Tranexamic Acid injection for a myomectomy operation, which ultimately leads to potential complications for patients. CASE PRESENTATION: A 33-year-old HIV-positive woman with dysmenorrhea for two years was diagnosed with uterine fibroids and scheduled for a myomectomy. After spinal anesthesia, the patient developed nonresponsive myoclonic seizures, so she was sedated, intubated, and hooked up to a mechanical ventilator. However, her condition continued to deteriorate, and she developed narrow complex tachycardia, which was controlled but later developed systole and she died. A second check for anesthetic drugs revealed that she was given tranexamic acid rather than bupivacaine. DISCUSSION: a succinct review was done to analyze the available current published data in the PubMed database about the problem, which concludes that it was described more often in developing countries. This is due to low obedience to medication safety procedures when managing drugs in operation rooms; however, more data is required to validate this assumption. Tranexamic acid is usually safe however improper use may cause catastrophic Gastrointestinal, cardiac and neurological complications. CONCLUSION: Suggestions are put together for the local drug enterprises to modify the appearance of the drug ampoules to reduce the possibility of similar incidents in the time to come. Implement drug preparation systems and double-check the medications before administration by more than one anesthesia staff.