• Christopher L Pysyk and Lucie Filteau.
• The Ottawa Hospital, General Campus, Ottawa, ON, Canada. cpysyk@toh.ca.
• Can J Anaesth. 2022 Sep 1; 69 (9): 116911731169-1173.

PurposeTranexamic 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 FeaturesA 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.ConclusionsSaline 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.© 2022. Canadian Anesthesiologists' Society.

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