Accidental intrathecal administration of dopamine in spinal anaesthesia for caesarean section: A case report

Publication date: Available online 2 September 2016 Source:Egyptian Journal of Anaesthesia Author(s): Udita Naithani, Devendra Verma, Abhilasha Thanvi, Rekha Bayer Inadvertent intrathecal administration of a wrong drug can be a catastrophic event. We are reporting a case of 24year old female patient who underwent elective caesarean section for oligohydramnios. During subarachnoid block resident doctor wrongly loaded 2ml of Dopamine hydrochloride (80mg) in the syringe assuming it to be 0.5% hyperbaric bupivacaine and injected it intrathecally. After 5min there was no sensory-motor blockade and the senior anaesthesiologist identified the mistake that dopamine had been administered in place of bupivacaine. Immediately general anaesthesia was induced and a healthy, male baby was delivered. Cardiovascular changes in the form of hypertension, tachycardia, extrasystoles and irregular rhythm did occur but were promptly treated. No neurological complications occurred, the patient was successfully extubated and discharged on the 7th postoperative day uneventfully. We conclude that before administration, drug labels should be carefully read to avoid medication errors from lookalike ampoules.
Source: Egyptian Journal of Anaesthesia - Category: Anesthesiology Source Type: research