Accidental administration of tranexamic acid into the epidural space: a case report

Area of Science:

• Anesthesiology
• Pharmacology
• Patient Safety

Background:

• Tranexamic acid is commonly used intravenously for surgical bleeding.
• Epidural administration of tranexamic acid has not been previously documented.
• Drug errors involving medication routes can have serious consequences.

Observation:

• A case report details an inadvertent administration of tranexamic acid into the epidural space.
• The medication was intended for intravenous use but was connected to an epidural catheter via Luer-type connectors.
• This highlights a potential risk of misconnection between intravenous and neuraxial administration sets.

Findings:

• The study describes the management and investigation of this specific drug error.
• Neurologic monitoring and multidisciplinary team involvement were crucial in patient management.
• Saline lavage of the epidural space was considered as a potential intervention.

Implications:

• This case underscores the importance of vigilance in medication administration routes.
• Recommendations include considering neuraxial route-specific connectors to prevent Luer-type misconnections.
• Enhanced protocols for medication verification and administration are essential for patient safety in neuraxial procedures.