Tranexamic acid at cesarean delivery: drug-error deaths

Area of Science:

• Obstetrics and Gynecology
• Anesthesiology
• Patient Safety

Background:

• Tranexamic acid is a critical treatment for postpartum hemorrhage (PPH).
• Its use during cesarean delivery is common for managing severe hemorrhage.
• Inadvertent intrathecal administration of tranexamic acid has been reported.

Purpose of the Study:

• To highlight the severe neurotoxicity and high mortality associated with intrathecal tranexamic acid administration.
• To emphasize the increasing incidence of this catastrophic medication error.
• To propose strategies for preventing inadvertent intrathecal tranexamic acid administration.

Main Methods:

• Review of reported cases of inadvertent intrathecal tranexamic acid administration.
• Analysis of the neurotoxic effects and outcomes of this error.
• Evaluation of existing drug safety alerts and recommendations.

Main Results:

• Intrathecal tranexamic acid causes rapid-onset convulsions and has a 50% mortality rate.
• Reported cases of this error are increasing despite existing safety alerts.
• Current safety measures are insufficient to prevent these tragic events.

Conclusions:

• Enhanced awareness and stringent hospital protocols are essential to avert intrathecal tranexamic acid errors.
• Storing tranexamic acid separately from anesthetics, ideally outside the operating room with warning labels, is recommended.
• Large-scale implementation of safety strategies is needed to prevent drug-error mortality and preserve tranexamic acid's life-saving benefits.