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Intrathecal tranexamic acid is a devastating error with mortality as high as 50%.
Patel S, Robertson B, McConachie I. Catastrophic drug errors involving tranexamic acid administered during spinal anaesthesia. Anaesthesia. 2019 Jul 1; 74 (7): 904-914.
  Daniel Jolley
summary
1
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?
• Block failure.
• Severe back and buttock pain (universal).
• Seizures.
• HT, tachycardia, arrhythmias, CVS collapse.
How should it be managed?
There are three components to managing intrathecal TXA:
1. Treating TXA-induced seizures with anticonvulsants: magnesium; benzodiazepines; barbiturates (thiopentone); phenytoin; possibly propofol. Thiopentone infusion was frequently required to terminate seizures.
2. 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.
3. Haemodynamic monitoring & support
How does this happen?
In almost all cases ampoule identification error was the primary cause.
Human factor contributions identified were:
1. Failure to check ampoule label.
2. Similar ampoule appearance.
3. Spinal catheter mistaken for IV (1).
4. Lack of drug handling and storage policies.
5. Storage of tranexamic acid with LA or lack of physical separation.
6. Underestimating potential for error.
"All errors could have been prevented..."
Patel S, Robertson B, McConachie I. Catastrophic drug errors involving tranexamic acid administered during spinal anaesthesia. Anaesthesia. 2019 Jul 1; 74 (7): 904-914.
  Daniel Jolley
pearl
1
Tranexamic acid (TXA) used in the management of post-partum haemorrhage (PPH) reduces maternal mortality without increase in thromboembolic events.
WOMAN Trial Collaborators. Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial. Lancet. 2017 May 27; 389 (10084): 2105-2116.
  Daniel Jolley
summary
1
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.
What were the most common human factors causing the errors?
• Similar drug ampoule appearance.
• Drug storage problems.
Any recommendations to reduce the risk of drug errors?
1. Carefully read the ampoule before drawing up, and the syringe label before administering.
2. Label syringes!
3. Check labels with a second person or a device.
4. Use non–luer lock connectors on all neuraxial catheters & devices.
Patel S Loveridge R. Obstetric Neuraxial Drug Administration Errors: A Quantitative and Qualitative Analytical Review. Anesth. Analg. 2015 Dec 1;121(6):1570-7.
  Daniel Jolley
pearl
1
The quadratus lumborum block (QLB) may be more effective than transversus abdominos plane (TAP) block for cesarean section analgesia.
Blanco R, Ansari T, Riad W et al. Quadratus Lumborum Block Versus Transversus Abdominis Plane Block for Postoperative Pain After Cesarean Delivery: A Randomized Controlled Trial. Reg Anesth Pain Med. 2016 Nov 1; 41 (6): 757-762.
  Daniel Jolley
pearl
1
Quadratus lumborum block may improve analgesia and reduce morphine use after Caesarean section.
Blanco R, Ansari T, Girgis E. Quadratus lumborum block for postoperative pain after caesarean section: A randomised controlled trial. Eur J Anaesthesiol. 2015 Nov 1; 32 (11): 812-8.
  Daniel Jolley
pearl
1
Topical liquorice halves the incidence of intubation-related sore throat, along with reducing pain severity.
Kuriyama A Maeda H. Topical application of licorice for prevention of postoperative sore throat in adults: A systematic review and meta-analysis. J Clin Anesth. 2019 May 1; 54: 25-32.
  Daniel Jolley
pearl
1
The benefit of preoperative prehabilitation before undergoing major abdominal cancer surgery is still unclear. Appropriate patient selection is likely a major influence.
Thomas G, Tahir MR, Bongers BC et al. A systematic review of randomised controlled trials investigating prehabilitation before major intra-abdominal cancer surgery: An analysis of prehabilitation content and outcome measures. Eur J Anaesthesiol. 2019 Dec 1; 36 (12): 933-945.
  Daniel Jolley
pearl
1
The use of Absalom and Kataria propofol TCI and Minto remifentanil TCI algorithms, along with processed EEG (BIS; Entropy), makes Total Intravenous Anaesthesia (TIVA) practical in children.
Anderson BJ Bagshaw O. Practicalities of Total Intravenous Anesthesia and Target-controlled Infusion in Children. Anesthesiology. 2019 Jul 1; 131 (1): 164-185.
  Daniel Jolley
pearl
1
Multiple laryngoscopy attempts in infants is associated with increased hypoxia risk.
Gálvez JA, Acquah S, Ahumada L et al. Hypoxemia, Bradycardia, and Multiple Laryngoscopy Attempts during Anesthetic Induction in Infants: A Single-center, Retrospective Study. Anesthesiology. 2019 Oct 1; 131 (4): 830-839.
  Daniel Jolley