Resumo

OJEDA-MARTELL, Rolando Ernesto; DIAZ-LUIS, Olimpia  e  ALVAREZ-VALDES, Mara Verónica. Fatal accident due to the use of intrathecal tranexamic acid. Case report. Rev.Med.Electrón. [online]. 2023, vol.45, n.5, pp. 884-891.  Epub 31-Out-2023. ISSN 1684-1824.

Errors in the drugs administration during anesthesia continue to be a major cause of morbidity and mortality, even in industrialized countries. Tranexamic acid is an antifibrinolytic agent indicated to reduce perioperative bleeding in several surgical procedures. The case of a 23-years-old pregnant woman with 32.7 weeks of pregnancy treated at the Baringo Referral Hospital, in Kenya, is presented. During the administration of spinal anesthesia in the cesarean section, this medication was accidentally applied intrathecally. The patient began with myoclonus of the lower limbs, tonic-clonic seizures, and reached cardio-respiratory arrest. She was admitted to Intensive Care, where indirect signs of brain death were identified, and she died on the six day after admission. The literature reports that mortality for this anesthetic accident is very high, due to high concentration of the drug in the cerebrospinal fluid.

Palavras-chave : tranexamic acid; spinal anesthesia; encephalic death.

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