Inadvertent intrathecal dobutamine administration and barbiturate induced nystagmus: A case report.
- Author:
In Yeob BAEK
1
;
Ji Uk YOON
;
Hyun Jun CHO
;
Nam Won KIM
;
Gyeong Jo BYEON
;
Hyae Jin KIM
Author Information
1. Department of Anesthesiology and Pain Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea. jiuk@pusan.ac.kr
- Publication Type:Case Report
- Keywords:
Accidental;
Dobutamine;
Intrathecal;
Medication errors;
Nystagmus
- MeSH:
Anesthesia;
Anesthesia, General;
Anesthesia, Spinal;
Barbiturates;
Bupivacaine;
Central Nervous System;
Dobutamine;
Humans;
Medication Errors;
Perioperative Period;
Sodium;
Vital Signs
- From:Anesthesia and Pain Medicine
2013;8(1):26-29
- CountryRepublic of Korea
- Language:English
-
Abstract:
Medication errors remain an unsolved problem in medicine. Some factors have been found to contribute to drug errors, and among them, the incorrect administration of drugs is a major factor. In this case report, 2 ml of dobutamine was inadvertently injected intrathecally instead of bupivacaine owing to ampoule confusion during spinal anesthesia, followed by the induction of general anesthesia with sodium thiopental-sevoflurane. It was uneventful during perioperative period, however, nystagmus was observed in post anesthesia care unit (PACU), about 1 h after induction of general anesthesia. There were no other neurologic abnormalities except nystagmus and vital sign were stable during PACU stay. Nystagmus subsided spontaneously and it was confirmed there was no evidence of any central nervous system lesion on imaging study. The patient was discharged 5 days later without any complications.
