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Administración epidural accidental de sugammadex y ramosetrón - Un informe de caso
Ji Wook Kim1, Taek Yong Ko2, Donghee Kang1
1Department of Anesthesiology and Pain Medicine, Kosin University College of Medicine, Busan, Korea.
Anesthesia and pain medicine
|February 10, 2026
Resumen
Se produjo una inyección epidural accidental de sugammadex y ramosetron, pero no resultó en daño a largo plazo. Este caso pone de relieve la necesidad crítica de vigilancia en la administración perioperatoria de medicamentos para evitar errores de administración por la ruta incorrecta.
Área de la Ciencia:
- Anestesiología Anestesiología.
- Farmacología Farmacología.
- La seguridad del paciente.
Sus antecedentes:
- La administración por vía incorrecta de medicamentos intravenosos (IV) en el espacio epidural es un evento raro pero potencialmente dañino.
- Los informes anteriores de inyección epidural inadvertida no incluyen sugammadex o ramosetron.
Objetivo del estudio:
- Para reportar el primer incidente de inyección epidural accidental de sugammadex y ramosetron.
- Hacer hincapié en la importancia de los protocolos de seguridad de los medicamentos en la atención perioperatoria.
Principales métodos:
- Un informe de caso de una paciente de 69 años que se sometió a anestesia general con analgesia epidural torácica.
- La inyección epidural accidental de sugammadex (200 mg) y ramosetron (0.3 mg) fue reconocida en 5 minutos.
- El manejo del paciente incluía proceder con la aparición de la anestesia y la posterior administración intravenosa de sugammadex.
Principales resultados:
- El paciente no experimentó efectos adversos inmediatos después de la administración por la ruta incorrecta.
- Después de la cirugía, el paciente desarrolló debilidad del tríceps derecho y hormigueo dermatomal bilateral C8.
- Los síntomas neurológicos se resolvieron en el segundo día postoperatorio, sin secuelas duraderas.
Conclusiones:
- A pesar de un resultado benigno, este evento subraya los riesgos asociados con la entrega de medicamentos por la ruta equivocada.
- Destaca la necesidad de una mayor vigilancia y estrategias preventivas en la gestión perioperatoria de la medicación.
- Refuerza la importancia de controles de seguridad robustos para evitar errores de medicación.
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