Print version ISSN 0034-7094
Rev. Bras. Anestesiol. vol.54 no.5 Campinas Sept./Oct. 2004
Accidental spinal metoclopramide injection. Case report*
Inyección inadvertida de metoclopramida en el espacio subaracnoideo. Relato de caso
Eduardo Barbosa Leão, M.D.I; Guilherme Antônio Moreira de Barros, M.D.II; Yara Marcondes Machado Castiglia, TSA, M.D.III; Eliana Marisa Ganem, TSA, M.D.IV
IME2 do CET/SBA do Departamento
de Anestesiologia da FMB-UNESP
IIDoutorando de Anestesiologia da FMB-UNESP e Médico da Disciplina de Terapia Antálgica e Cuidados Paliativos da FMB-UNESP
IIIProfessora Titular do Departamento de Anestesiologia da FMB-UNESP
IVProfessora Adjunta Livre-Docente do Departamento de Anestesiologia da FMB-UNESP
BACKGROUND AND OBJECTIVES: Accidental
injection of non-spinal drugs in epidural and spinal spaces is a possible anesthetic
complication. This report presents a case of inadvertent spinal metoclopramide
CASE REPORT: Female patient, 17 years old, 69 kg, BMI = 26.2, physical status ASA I, 36 weeks and 4 days gestation, with acute fetal suffering and C-section indication. Patient presented with heart rate of 82 bpm, blood pressure of 130 x 70 mmHg, SpO2 of 97% and regular sinusoidal cardiac rhythm. Spinal anesthesia performed with a local anesthetic and opioid association, 15 mg of 0.25% hyperbaric bupivacaine and 25 µg fentanyl. Patient referred unspecific "discomfort" 5 minutes after blockade installation. Blood pressure was 190 x 120 mmHg, heart rate was 145 bpm and SpO2 was 95%. Checking the vials, one bupivacaine vial and one metoclopramide vial were found. Symptoms were severe frontal headache, blurred view, nausea, vomiting and initial agitation evolving to sleepiness and torpor, in addition to hypertension and tachycardia. Tramadol, dipyrone, ondansetron and support measures were administered. Patient was asymptomatic 30 minutes after with BP of 150 x 100 mmHg and HR of 120 bpm. Patient was discharged from PACU to the ward 140 minutes after with sensory, motor and autonomic block recovery and normal hemodynamic parameters. Patient was discharged 48 hours later without neurological sequelae, together with the neonate.
CONCLUSIONS: Close attention should be paid to any administered drug, regardless of the route. It is desirable to standardize vial colors and storage sites aiming at minimizing this type of accident.
Key Words: ANESTHETIC TECHNIQUES: Regional, spinal block; ANTIEMETICS: metoclopramide; COMPLICATIONS: accidental injection
JUSTIFICATIVA Y OBJETIVOS: Inyección
inadvertida de medicamentos de uso no espinal en los espacios peridural y subaracnoideo
es una complicación anestésica pasible de ocurrir. Este relato presenta
un caso de inyección inadvertida de metoclopramida en el espacio subaracnóideo.
RELATO DEL CASO: Paciente del sexo femenino, 17 años, 69 kg, IMC de 26.2, estado físico ASA I, 36 semanas y 4 días de gestación, con diagnóstico de sufrimiento fetal agudo, e indicación de cesárea. Presentaba frecuencia cardíaca de 82 bpm, presión arterial de 130 x 70 mmHg, SpO2 de 97%, ritmo cardíaco sinusal regular. La anestesia fue por vía subaracnoidea con la asociación de anestésico local y opioide, 15 mg de bupivacaína hiperbárica a 0,5% y 25 µg de fentanil. Después de 5 minutos de la instalación del bloqueo, la paciente mencionó "mal estar" inespecífico. Aferidas presión arterial, 190 x 120 mmHg, frecuencia cardíaca, 145 bpm, y SpO2, 95%. Verificándose las ampollas cuyos contenidos fueron administrados se encontró una de bupivacaína y una de metoclorpramida. El cuadro se presentó con cefalea frontal intensa, visión turbia, náuseas, vómitos y agitación inicial, que evoluyó para somnolencia y torpor, además de hipertensión arterial y taquicardia. Fueron administrados tramadol, dipirona, ondansetron y medidas de soporte. Después de 30 minutos, la paciente se presentaba asintomática, con PA de 150 x 100 mmHg y FC de 120 bpm. Recibió alta para la enfermaria 140 minutos después de permanencia en la SRPA, con total reversión de los bloqueos motor, sensitivo y autonomico, y normalización de los parámetros hemodinámicos. Recibió alta hospitalar 48 horas después, sin presentar secuelas neurológicas, juntamente con el recién-nacido.
CONCLUSIONES: Máxima atención debe ser dada a cualquier medicamento administrado, sea cual sea la vía utilizada. Patronización de colores de ampollas, y de los locales de depósito, con la finalidad de diminuir este tipo de accidente es recomendable.
Opioids associated to local anesthetics aiming at improving quality and speed of spinal block installation are popular in current anesthetic practice 1-3. Especially for obstetric patients anesthesia, this association is extremely safe and effective 4-7. So, a significant number of drugs commercially available may be spinally administered 8-10.
Hospital gases pipelines have international color standards, however the same is not true for vials. So, it is possible to accidentally inject drugs presented in very similar vials. This report aimed at describing a case of inadvertent spinal metoclopramide injection in an obstetric patient.
Female patient, 17 years old, 69kg, 1.62 m, physical status ASA I, 36 weeks and 4 days gestation, to be submitted to emergency C-section due to acute fetal suffering. Preanesthetic evaluation was performed in the obstetric center. Patient was anxious and concerned, however cooperative.
Monitoring consisted of continuous ECG, pulse oximetry, sphygmomanometer, stethoscope and vesical probe. At monitoring, patient presented heart rate of 82 bpm, blood pressure of 130 x 70 mmHg, SpO2 of 97% and regular sinusoidal cardiac rhythm. Venoclysis was performed with 18G catheter in the left forearm and volume expansion was achieved with lactated Ringers (10 mL.kg-1).
Spinal anesthesia with the association of local anesthetic and opioids was decided after preanesthetic evaluation. One 0.5% hyperbaric bupivacaine vial and one spinal fentanyl vial were separated by the anesthesiologist and placed on the anesthetic equipment table to be used in the procedure. Close to previously selected vials, there were others to be used if necessary. Among them, there were some metoclopramide vials.
Patient was placed in the sitting position and skin was thoroughly cleaned. The nurse opened the 0.5% hyperbaric bupivacaine vial and gave it to the anesthesiologist. With a 5 mL disposable syringe, 5 mL of this vial content were aspirated. Then, "fentanyl" vial was asked and the nurse repeated the same procedure. With an adequate and disposable syringe, 0.5 mL of this second vial content were aspirated.
Spinal puncture was performed with 26G Quincke needle in L3-L4 interspace without intercurrences. After obtaining clear and normotensive CSF, "fentanyl" was injected, followed by 3 mL of 0.5% hyperbaric bupivacaine in 60 seconds. Patient was placed in the supine position with the uterus displaced to the left, while waiting for anesthetic block installation.
Onset was normal. When sensory block reached T4 and no blood pressure changes were observed, the surgical procedure was authorized. Patient referred unspecific "discomfort" 5 minutes after blockade installation.
At this point, the anesthesiologist, considering possible hypotension, palpated the radial pulse and confirmed tachycardia with full pulse. Blood pressure was 190 x 120 mmHg, heart rate 145 bpm and SpO2 95%. 100% oxygen with 4 L.min-1 flow under facial mask was promptly administered.
Patient was asked about pain related to the surgical procedure and the answer was negative, confirming adequate sensory block installation. Pain was then ruled out as responsible for the symptoms. The nurse was asked to show the vials administered. For the anesthesiologists surprise, a metoclopramide vial (with green letters) from Teuto Laboratory and a hyperbaric bupivacaine vial (also with green letters) from Cristália Laboratory were presented. Both had the same shape and size, and were very similar.
Symptoms evolved with severe frontal headache, blurred view, nausea, vomiting and initial agitation evolving to sleepiness and torpor, in addition to hypertension and tachycardia. Patient was positioned 30 degrees head up, tramadol (50 mg), dipyrone (1.5 g) and ondansetron (4 mg) diluted in 100 mL lactated Ringers were promptly administered and support measures were maintained.
Twenty minutes after beginning of symptoms patient had improved consciousness level and reported headache and nausea relief, however maintaining blood pressure of 150 x 100 mmHg and heart rate of 120 bpm. Neonate was extracted 5 minutes after the beginning of surgery with Apgar scores of 8, 9 and 9 at 5, 10 and 15 minutes, respectively.
Surgery lasted 65 minutes and patient was then referred to the PACU were partial motor block recovery was observed 20 minutes after arrival. Patient was discharged to the ward 145 minutes after PACU admission with total motor, sensory and autonomic block recovery and normal hemodynamic parameters (Figure 1).
Detailed neurological tests were performed during the next 24 hours and have not evidenced any sign of neurological sequelae. Patient and neonate were discharged together 48 h after.
Several non-spinal drugs have already been inadvertently administered in epidural or spinal spaces 11-14. Many cases have not been published, as confirmed by the large number of not notified cases however shared with hospital colleagues and during congresses. This way, they are not examples and alerts for the anesthesiologists. The related cases published are relatively uncommon and involve especially gallamine 15-19.
Nervous tissue is extremely sensitive to chemicals, including local anesthetics, which are drugs specifically developed to be used in this tissue 20-24. When local anesthetics are administered in different than preconized pH, or with not recommended osmolarity, or even in high concentrations, they may promote nervous fiber demyelination 25,26. It is then clear the potential risk for nervous tissue injury when drugs not specifically developed for spinal administration are used.
Major causes for inadvertent drug injection in the anesthetic practice seem to be related to the similarity of different drug presentations, added to physical and mental stress and especially in situations where time is critical to decrease surgical mortality.
This report, in addition to matching above-mentioned situations, shows the mistake of allowing similar drugs to be placed side by side. One suggestion to prevent this type of accident would be vials standardization, be it externally, be it in the color of injectable drugs.
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Dr. Eduardo Barbosa Leão
Av. Caetité 175, Centro
46190-000 Paramirim, Brazil
Submitted for publication October 21, 2003
Accepted for publication February 16, 2004
* Received from Departamento de Anestesiologia da Faculdade de Medicina de Botucatu da Universidade Estadual de São Paulo (FMB UNESP), Botucatu, SP