Inadvertent spinal injection of ondansetron

Area of Science:

• Anesthesiology
• Neuroscience
• Pharmacology

Background:

• Cesarean sections under spinal anesthesia are common procedures in tertiary hospitals.
• Spinal anesthesia is a widely used method for surgical anesthesia, particularly in obstetrics.
• Medication errors can occur during drug administration, especially in high-pressure environments.

Observation:

• A patient undergoing elective Cesarean section under spinal anesthesia received an inadvertent intrathecal injection of ondansetron.
• The medication was administered via a 2 mL ampule, visually similar to other drugs used during the procedure.
• The patient was closely monitored for any adverse neurological effects or typical side effects of neuraxial medications.

Findings:

• The patient experienced no permanent neurological sequelae following the inadvertent spinal ondansetron injection.
• Absence of central neuraxial opioid side effects such as nausea, vomiting, or pruritus was noted.
• This case suggests a potential for ondansetron to be tolerated intrathecally without severe neurological complications.

Implications:

• Highlights the critical importance of meticulous drug identification and administration protocols in anesthesia.
• Underscores the need for enhanced vigilance to prevent wrong-route medication errors, especially with look-alike drug packaging.
• Suggests further investigation into the safety profile of ondansetron in accidental intrathecal administration, though caution is advised.