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Ventriculolumbar perfusion and inhalational anesthesia with sevoflurane in an accidental intrathecal injection of tranexamic acid: unreported treatment options
  1. Sergej Godec1,
  2. Michael Jozef Gradisek1,
  3. Tomislav Mirkovic1,2 and
  4. Primoz Gradisek1,2
  1. 1Clinical Department of Anaesthesiology and Intensive Therapy, University Medical Center, Ljubljana, Slovenia
  2. 2Department of Anaesthesiology, University of Ljubljana, Faculty of Medicine, Ljubljana, Slovenia
  1. Correspondence to Dr Primoz Gradisek, Clinical Department of Anaesthesiology and Intensive Therapy, University Medical Center, 1000 Ljubljana, Slovenia; primoz.gradisek{at}


Background Tranexamic acid (TXA) decreases hemorrhage-related mortality in trauma patients and is increasingly being used during obstetric and orthopedic surgeries. Inadvertent intrathecal injection of TXA is a rare, potentially lethal event leading to dose-dependent cardiotoxicity and neurotoxicity. TXA enhances neuronal excitation by antagonizing inhibitory γ-aminobutyric acid type A and glycine receptors. Until now, mechanistic-based pharmacological treatments targeting multiple central nervous system receptors have been advocated for use in such cases, with no data on intrathecal TXA elimination techniques.

Case presentation A patient scheduled for hip surgery accidentally received 350 mg of intrathecal TXA instead of levobupivacaine. The clinical picture progressed from spinal segmental myoclonus to generalized convulsions and malignant arrhythmias. The treatment consisted of ventriculolumbar perfusion with normal saline at a rate of 50 mL/hour starting 5 hours after TXA administration and inhalational sedation with sevoflurane, in addition to drugs acting on multiple receptors at different central nervous system levels. Over 2 months the neurological status improved, although it was not complete.

Conclusions For the first time, the feasibility and possible clinical efficacy of combined treatment with ventriculolumbar perfusion and inhalational sedation with sevoflurane were demonstrated. A referral to a neurosurgical facility is recommended in patients with acute TXA-induced neurotoxicity and cardiotoxicity.

  • injections
  • spinal
  • drug-related side effects and adverse reactions
  • ambulatory care
  • diagnostic techniques and procedures
  • neurotoxicity syndromes

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  • Contributors SG, MJG, TM, and PG designed the work and collected the data. SG and PG drafted the work. All authors revisited and approved the work.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.