In Practice

Intrathecal tranexamic acid during spinal anaesthesia for caesarean delivery: A lethal drug error

D G Bishop, A C Lundgren, N F Moran, I Popov, J Moodley

Abstract


The National Committee on Confidential Enquiries into Maternal Deaths recently received notification of a death in South Africa caused by inadvertent intrathecal administration of tranexamic acid (TXA). TXA is increasingly used during caesarean delivery following updated recommendations from the World Health Organization in 2017. However, its greater availability has led to an international rise in drug errors during obstetric spinal anaesthesia. This case highlights a growing clinical risk, of which all operating theatre staff should be aware. Review of existing operating theatre drug handling practices is required in order to decrease this risk. Recommendations are made that aim to minimise drug errors associated with the use of this potentially life-saving intervention.


Authors' affiliations

D G Bishop, Department of Anaesthesia, School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, Pietermaritzburg, South Africa

A C Lundgren, Steve Biko Centre for Bioethics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

N F Moran, KwaZulu-Natal Department of Health; and Department of Obstetrics and Gynaecology, School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa

I Popov, Department of Gynaecology and Obstetrics, Port Shepstone Regional Hospital, KwaZulu-Natal, South Africa

J Moodley, Women’s Health and HIV Research Group, Department of Obstetrics and Gynaecology, School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa

Full Text

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Keywords

Obstetric spinal anaesthesia; Drug error; Tranexamic acid

Cite this article

South African Medical Journal 2019;109(11):841-844. DOI:10.7196/SAMJ.2019.v109i11.14242

Article History

Date submitted: 2019-10-31
Date published: 2019-10-31

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