Accidental spinal administration of tranexamic acid during anaesthesia catastrophic but avoidable

The incidence and significance of drug errors during anaesthesia are often underappreciated. Administration of the wrong drug during neuraxial (epidural and spinal) anaesthesia can lead to devastating consequences. In a recent study, published in the journal Anaesthesia, the researchers reviewed the reports of accidental tranexamic acid administration during the spinal block, the pharmacokinetics and mechanisms of toxicity of tranexamic acid, as well as strategies for prevention of occurrence in the future.

Tranexamic acid is an analogue of the amino acid lysine, which acts as an antifibrinolytic by reversibly binding to lysine receptor sites on plasminogen, thereby preventing the degradation of fibrin. It is used to treat or prevent excessive blood loss in control of traumatic, surgical and obstetric haemorrhage.

Overall, there is increased availability and use of tranexamic acid in operating theatres and labour wards, which has increased the risks of drug errors.

Authors of the study have previously reviewed reports of drug administration errors during neuraxial (epidural and spinal) anaesthesia and analgesia, and made recommendations to limit their occurrence.

Recommendations include:

• Use non–luer lock connectors on all epidural, spinal and combined spinal-epidural devices.


• Check labels with a second person or a device, such as a barcode reader linked to a computer, before the drug is drawn up and/or administered.


• Label all syringes.


• Carefully read the drug ampule and syringe labels before the drug is drawn up or injected.

"In addition to the four recommendations in our report, tranexamic acid ampoule design by manufacturers, dispensing and distribution by pharmacy and its storage at the site of administration requires attention. Clinicians managing patients who have received an accidental spinal injection of tranexamic acid should consider performing CSF lavage," the authors write in the present study.

For the current review, the researchers performed a MEDLINE search of cases of administration of tranexamic acid during epidural or spinal anaesthesia between 1960 and 2018. They included only articles on tranexamic acid administration during central neuraxial anaesthesia or analgesia. Articles were excluded if they reported solely on tranexamic acid errors involving other routes.

Key findings:

• 21 reports of accidental spinal administration of tranexamic acid injected were identified during spinal anaesthesia or analgesia.


• There were seven elective caesarean sections and six patients having orthopaedic surgery.


• The typical signs and symptoms that were reported included: no sensory or motor block; severe pain in the back, buttocks and legs; myoclonus starting in the legs leading to generalised convulsions; severe tachycardia and hypertension; and ventricular arrhythmia.


• Death was reported in 10 patients, giving a mortality rate of just under 50%. In the remaining 11 patients, 10 required intensive care admission for management of refractory convulsions and/or tachyarrhythmias.


• In two patients, cerebrospinal fluid (CSF) lavage was performed and for one patient spinal anaesthesia was repeated.


• Three patients required long‐term rehabilitation after discharge from the hospital.


• Six of seven patients having caesarean section died, although in one the immediate cause was a failure of the hospital oxygen supply.


• In 20 patients there was an ampoule error (not checking or reading the label; similar size ampoules; similar printing on the labels; the similar appearance of ampoules); in the remaining patient there was confusion between an intravenous (i.v.) line and a spinal catheter


• All errors could have been prevented if the four recommendations highlighted above had been followed.


• There were no reports of accidental epidural administration of tranexamic acid. This is likely to be because tranexamic acid can be confused with the hyperbaric preparation of bupivacaine available in some countries.

"Spinal tranexamic acid errors are exceedingly high risk. To our knowledge, no other drug has caused such a level of iatrogenic harm in regional anaesthesia practice. Skill‐based errors involving wrong drug administration during regional anaesthesia require the robust implementation of targeted prevention strategies," concluded the authors.

To read the complete study follow the link: https://doi.org/10.1111/anae.14662