-
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...
- A Palanisamy and S M Kinsella.
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA.
- Anaesthesia. 2019 Jul 1; 74 (7): 831-833.
no abstract available
This article appears in the collection: Inadvertent spinal tranexamic acid: a devastating error.
Notes
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...
Daniel Jolley
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