Anesth Pain Med.  2013 Jan;8(1):26-29.

Inadvertent intrathecal dobutamine administration and barbiturate induced nystagmus: A case report

• Baek IY
• Yoon JU
• Cho HJ
• Kim NW
• Byeon GJ
• Kim HJ

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.

Keyword

Accidental; Dobutamine; Intrathecal; Medication errors; Nystagmus

MeSH Terms

Anesthesia
Anesthesia, General
Anesthesia, Spinal
Barbiturates
Bupivacaine
Central Nervous System
Dobutamine
Humans
Medication Errors
Perioperative Period
Sodium
Vital Signs
Barbiturates
Bupivacaine
Dobutamine
Sodium