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Background and Aims Medication errors are a common source of iatrogenicity. Intrathecal administration of wrong drugs can be life-threatening. A patient suffered an anaphylactic shock after accidental intradural administration of atropine. The aim of this work is to find out if these two facts were related.
Methods Performing spinal anesthesia for postoperative pain treatment, inadvertent intrathecal inyection of 0.2 mg of atropine instead of morphic chloride occurred to a patient. General anesthesia was induced and then the error was discovered. Surgery was performed without incidents until intravenous administration of metamizole, when severe hypotension underwent. It was resolved with norepinephrine and epinephrine and he recovered without sequelae. Investigating about this episode, authors carried out a bibliographic search in Pubmed, without limiting dates, for studies in which intrathecal administration of atropine was described, in order to find similar cases, consequences and its management.
Results We found that intrathecal atropine is described by several studies as prevention of postoperative nausea and vomiting after caesarean section with spinal anesthesia. As far as the patient was concern, subsequent allergy testing showed that he was allergic to metamizole, concluding that the episode of hypotension had been consequence of an anaphylactic shock due to this drug, and no related with the medication error.
Conclusions It has been shown that anticholinergics can be used for prevention of postoperative nausea and vomiting in different routes of administration, including intrathecal route at small doses. Regarding medication errors, a good practice protocol is necessary to avoid serious consequences that, fortunately in this case, did not occur.
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