<?xml version="1.0" encoding="ISO-8859-1"?><article xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance">
<front>
<journal-meta>
<journal-id>1684-1824</journal-id>
<journal-title><![CDATA[Revista Médica Electrónica]]></journal-title>
<abbrev-journal-title><![CDATA[Rev.Med.Electrón.]]></abbrev-journal-title>
<issn>1684-1824</issn>
<publisher>
<publisher-name><![CDATA[Universidad de Ciencias Médicas de Matanzas]]></publisher-name>
</publisher>
</journal-meta>
<article-meta>
<article-id>S1684-18242023000500884</article-id>
<title-group>
<article-title xml:lang="es"><![CDATA[Accidente fatal debido al uso de ácido tranexámico vía intratecal. Presentación de caso]]></article-title>
<article-title xml:lang="en"><![CDATA[Fatal accident due to the use of intrathecal tranexamic acid. Case report]]></article-title>
</title-group>
<contrib-group>
<contrib contrib-type="author">
<name>
<surname><![CDATA[Ojeda-Martell]]></surname>
<given-names><![CDATA[Rolando Ernesto]]></given-names>
</name>
<xref ref-type="aff" rid="Aff"/>
</contrib>
<contrib contrib-type="author">
<name>
<surname><![CDATA[Díaz-Luis]]></surname>
<given-names><![CDATA[Olimpia]]></given-names>
</name>
<xref ref-type="aff" rid="Aff"/>
</contrib>
<contrib contrib-type="author">
<name>
<surname><![CDATA[Álvarez-Valdés]]></surname>
<given-names><![CDATA[Mara Verónica]]></given-names>
</name>
<xref ref-type="aff" rid="Aff"/>
</contrib>
</contrib-group>
<aff id="Af1">
<institution><![CDATA[,Hospital Universitario Clínico Quirúrgico Comandante Faustino Pérez Hernández  ]]></institution>
<addr-line><![CDATA[ Matanzas]]></addr-line>
<country>Cuba</country>
</aff>
<pub-date pub-type="pub">
<day>00</day>
<month>10</month>
<year>2023</year>
</pub-date>
<pub-date pub-type="epub">
<day>00</day>
<month>10</month>
<year>2023</year>
</pub-date>
<volume>45</volume>
<numero>5</numero>
<fpage>884</fpage>
<lpage>891</lpage>
<copyright-statement/>
<copyright-year/>
<self-uri xlink:href="http://scielo.sld.cu/scielo.php?script=sci_arttext&amp;pid=S1684-18242023000500884&amp;lng=en&amp;nrm=iso"></self-uri><self-uri xlink:href="http://scielo.sld.cu/scielo.php?script=sci_abstract&amp;pid=S1684-18242023000500884&amp;lng=en&amp;nrm=iso"></self-uri><self-uri xlink:href="http://scielo.sld.cu/scielo.php?script=sci_pdf&amp;pid=S1684-18242023000500884&amp;lng=en&amp;nrm=iso"></self-uri><abstract abstract-type="short" xml:lang="es"><p><![CDATA[RESUMEN Los errores en la administración de medicamentos durante la anestesia continúan siendo una causa importante de morbimortalidad, incluso en países industrializados. El ácido tranexámico es un agente antifibrinolítico indicado para reducir el sangramiento perioperatorio en varios procederes quirúrgicos. Se presenta el caso de una gestante de 23 años con 37,2 semanas de gestación, en el Baringo Country Referral Hospital, de Kenia. Durante la administración de la anestesia raquídea en la cesárea, se le aplicó de forma accidental este medicamento por vía intratecal. La paciente comenzó con mioclonías de miembros inferiores, convulsiones tonicoclónicas, y llegó a la parada cardiorrespiratoria. Se ingresó en Cuidados Intensivos, donde se identificaron signos indirectos de muerte encefálica, y falleció al sexto día de su ingreso. La literatura reporta que la mortalidad por este accidente anestésico en embarazadas es muy elevada, debido a altas concentraciones del medicamento en el líquido cefalorraquídeo.]]></p></abstract>
<abstract abstract-type="short" xml:lang="en"><p><![CDATA[ABSTRACT 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.]]></p></abstract>
<kwd-group>
<kwd lng="es"><![CDATA[ácido tranexámico]]></kwd>
<kwd lng="es"><![CDATA[anestesia raquídea]]></kwd>
<kwd lng="es"><![CDATA[muerte encefálica]]></kwd>
<kwd lng="en"><![CDATA[tranexamic acid]]></kwd>
<kwd lng="en"><![CDATA[spinal anesthesia]]></kwd>
<kwd lng="en"><![CDATA[encephalic death]]></kwd>
</kwd-group>
</article-meta>
</front><back>
<ref-list>
<ref id="B1">
<label>1</label><nlm-citation citation-type="journal">
<person-group person-group-type="author">
<name>
<surname><![CDATA[Sy Su]]></surname>
<given-names><![CDATA[KMC]]></given-names>
</name>
</person-group>
<article-title xml:lang=""><![CDATA[Accidental Intrathecal Administration of Tranexamic Acid: A Case Report]]></article-title>
<source><![CDATA[J Clin Anesth Pain Manag]]></source>
<year>2021</year>
<volume>5</volume>
<numero>2</numero>
<issue>2</issue>
<page-range>232-4</page-range></nlm-citation>
</ref>
<ref id="B2">
<label>2</label><nlm-citation citation-type="journal">
<person-group person-group-type="author">
<name>
<surname><![CDATA[Elkhateeb]]></surname>
<given-names><![CDATA[R]]></given-names>
</name>
<name>
<surname><![CDATA[Kamel]]></surname>
<given-names><![CDATA[HH]]></given-names>
</name>
</person-group>
<article-title xml:lang=""><![CDATA[Intrathecal Injection of Tranexamic Acid during Caesarean Section: Accidental Fatal Mistake]]></article-title>
<source><![CDATA[J Clin Obstet Gynecol Infertil]]></source>
<year>2017</year>
<volume>1</volume>
<numero>3</numero>
<issue>3</issue>
<page-range>1014</page-range></nlm-citation>
</ref>
<ref id="B3">
<label>3</label><nlm-citation citation-type="journal">
<person-group person-group-type="author">
<name>
<surname><![CDATA[Sanz Madurga]]></surname>
<given-names><![CDATA[M]]></given-names>
</name>
</person-group>
<article-title xml:lang=""><![CDATA[Ácido tranexámico: riesgo grave de error de medicación por vía intratecal inadecuada]]></article-title>
<source><![CDATA[Panorama Actual Med]]></source>
<year>2022</year>
<volume>46</volume>
<numero>453</numero>
<issue>453</issue>
<page-range>534-5</page-range></nlm-citation>
</ref>
<ref id="B4">
<label>4</label><nlm-citation citation-type="journal">
<person-group person-group-type="author">
<name>
<surname><![CDATA[Gupta]]></surname>
<given-names><![CDATA[S]]></given-names>
</name>
<name>
<surname><![CDATA[Bhiwal]]></surname>
<given-names><![CDATA[AK]]></given-names>
</name>
<name>
<surname><![CDATA[Sharma]]></surname>
<given-names><![CDATA[K]]></given-names>
</name>
</person-group>
<article-title xml:lang=""><![CDATA[Tranexamic Acid: Beware of Anaesthetic Misadventures]]></article-title>
<source><![CDATA[J Obstet Anaesth Crit Care]]></source>
<year>2018</year>
<volume>8</volume>
<numero>1</numero>
<issue>1</issue>
<page-range>1-6</page-range></nlm-citation>
</ref>
<ref id="B5">
<label>5</label><nlm-citation citation-type="journal">
<person-group person-group-type="author">
<name>
<surname><![CDATA[Ayala]]></surname>
<given-names><![CDATA[S]]></given-names>
</name>
</person-group>
<article-title xml:lang=""><![CDATA[Inyección intratecal inadvertida de ácido tranexámico]]></article-title>
<source><![CDATA[Rev Méd Urug]]></source>
<year>2021</year>
<volume>37</volume>
<numero>1</numero>
<issue>1</issue>
</nlm-citation>
</ref>
<ref id="B6">
<label>6</label><nlm-citation citation-type="journal">
<person-group person-group-type="author">
<name>
<surname><![CDATA[Patel]]></surname>
<given-names><![CDATA[S]]></given-names>
</name>
<name>
<surname><![CDATA[Robertson]]></surname>
<given-names><![CDATA[B]]></given-names>
</name>
<name>
<surname><![CDATA[McConachie]]></surname>
<given-names><![CDATA[I]]></given-names>
</name>
</person-group>
<article-title xml:lang=""><![CDATA[Catastrophic drug errors involving tranexamic acid administered during spinal anaesthesia]]></article-title>
<source><![CDATA[Anaesthesia]]></source>
<year>2019</year>
<volume>74</volume>
<numero>7</numero>
<issue>7</issue>
<page-range>904-14</page-range></nlm-citation>
</ref>
<ref id="B7">
<label>7</label><nlm-citation citation-type="journal">
<person-group person-group-type="author">
<name>
<surname><![CDATA[AL-Taei]]></surname>
<given-names><![CDATA[MH]]></given-names>
</name>
<name>
<surname><![CDATA[AlAzzawi]]></surname>
<given-names><![CDATA[M]]></given-names>
</name>
<name>
<surname><![CDATA[Albustani]]></surname>
<given-names><![CDATA[S]]></given-names>
</name>
</person-group>
<article-title xml:lang=""><![CDATA[Incorrect Route for Injection: Inadvertent Tranexamic Acid Intrathecal Injection]]></article-title>
<source><![CDATA[Cureus]]></source>
<year>2021</year>
<volume>13</volume>
<numero>2</numero>
<issue>2</issue>
</nlm-citation>
</ref>
<ref id="B8">
<label>8</label><nlm-citation citation-type="journal">
<person-group person-group-type="author">
<name>
<surname><![CDATA[Wong]]></surname>
<given-names><![CDATA[JO]]></given-names>
</name>
<name>
<surname><![CDATA[Yang]]></surname>
<given-names><![CDATA[SF]]></given-names>
</name>
<name>
<surname><![CDATA[Tsai]]></surname>
<given-names><![CDATA[MH]]></given-names>
</name>
</person-group>
<article-title xml:lang=""><![CDATA[Accidental injection of tranexamic acid (Transamin) during spinal anesthesia]]></article-title>
<source><![CDATA[Ma Zui Xue Za Zhi]]></source>
<year>1988</year>
<volume>26</volume>
<numero>2</numero>
<issue>2</issue>
<page-range>249-52</page-range></nlm-citation>
</ref>
<ref id="B9">
<label>9</label><nlm-citation citation-type="journal">
<person-group person-group-type="author">
<name>
<surname><![CDATA[Palanisamy]]></surname>
<given-names><![CDATA[A]]></given-names>
</name>
<name>
<surname><![CDATA[Kinsella]]></surname>
<given-names><![CDATA[SM]]></given-names>
</name>
</person-group>
<article-title xml:lang=""><![CDATA[Spinal tranexamic acid - a new killer in town]]></article-title>
<source><![CDATA[Anaesthesia]]></source>
<year>2019</year>
<volume>74</volume>
<numero>7</numero>
<issue>7</issue>
<page-range>831-3</page-range></nlm-citation>
</ref>
<ref id="B10">
<label>10</label><nlm-citation citation-type="journal">
<person-group person-group-type="author">
<name>
<surname><![CDATA[Shah]]></surname>
<given-names><![CDATA[P]]></given-names>
</name>
<name>
<surname><![CDATA[Agrawal]]></surname>
<given-names><![CDATA[P]]></given-names>
</name>
<name>
<surname><![CDATA[Nagaria]]></surname>
<given-names><![CDATA[A]]></given-names>
</name>
</person-group>
<article-title xml:lang=""><![CDATA[Fortuitous intrathecal injection of tranexamic acid]]></article-title>
<source><![CDATA[Indian J Anaesth]]></source>
<year>2021</year>
<volume>65</volume>
<numero>^s2</numero>
<issue>^s2</issue>
<supplement>2</supplement>
<page-range>S93-S5</page-range></nlm-citation>
</ref>
<ref id="B11">
<label>11</label><nlm-citation citation-type="journal">
<person-group person-group-type="author">
<name>
<surname><![CDATA[Bishop]]></surname>
<given-names><![CDATA[DG]]></given-names>
</name>
<name>
<surname><![CDATA[Lundgren]]></surname>
<given-names><![CDATA[AC]]></given-names>
</name>
<name>
<surname><![CDATA[Popov]]></surname>
<given-names><![CDATA[I]]></given-names>
</name>
</person-group>
<article-title xml:lang=""><![CDATA[Intrathecal tranexamic acid during spinal anaesthesia for caesarean delivery: A lethal drug error]]></article-title>
<source><![CDATA[S Afr Med J]]></source>
<year>2019</year>
<volume>109</volume>
<numero>11</numero>
<issue>11</issue>
<page-range>841-4</page-range></nlm-citation>
</ref>
<ref id="B12">
<label>12</label><nlm-citation citation-type="journal">
<person-group person-group-type="author">
<name>
<surname><![CDATA[Patel]]></surname>
<given-names><![CDATA[S]]></given-names>
</name>
<name>
<surname><![CDATA[Loveridge]]></surname>
<given-names><![CDATA[R]]></given-names>
</name>
</person-group>
<article-title xml:lang=""><![CDATA[Obstetric Neuraxial Drug Administration Errors: A Quantitative and Qualitative Analytical Review]]></article-title>
<source><![CDATA[Anesth Analg]]></source>
<year>2015</year>
<volume>121</volume>
<numero>6</numero>
<issue>6</issue>
<page-range>1570-7</page-range></nlm-citation>
</ref>
<ref id="B13">
<label>13</label><nlm-citation citation-type="journal">
<person-group person-group-type="author">
<name>
<surname><![CDATA[Lecker]]></surname>
<given-names><![CDATA[I]]></given-names>
</name>
<name>
<surname><![CDATA[Wang]]></surname>
<given-names><![CDATA[DS]]></given-names>
</name>
<name>
<surname><![CDATA[Whissell]]></surname>
<given-names><![CDATA[PD]]></given-names>
</name>
</person-group>
<article-title xml:lang=""><![CDATA[Tranexamic acid-associated seizures: Causes and treatment]]></article-title>
<source><![CDATA[Ann Neurol]]></source>
<year>2016</year>
<volume>79</volume>
<numero>1</numero>
<issue>1</issue>
<page-range>18-26</page-range></nlm-citation>
</ref>
<ref id="B14">
<label>14</label><nlm-citation citation-type="journal">
<person-group person-group-type="author">
<name>
<surname><![CDATA[Perkins]]></surname>
<given-names><![CDATA[GD]]></given-names>
</name>
<name>
<surname><![CDATA[Graesner]]></surname>
<given-names><![CDATA[JT]]></given-names>
</name>
<name>
<surname><![CDATA[Semeraro]]></surname>
<given-names><![CDATA[F]]></given-names>
</name>
</person-group>
<article-title xml:lang=""><![CDATA[European Resuscitation Council Guidelines 2021: executive summary]]></article-title>
<source><![CDATA[Resuscitation]]></source>
<year>2021</year>
<volume>161</volume>
<numero>1-60</numero>
<issue>1-60</issue>
</nlm-citation>
</ref>
<ref id="B15">
<label>15</label><nlm-citation citation-type="journal">
<person-group person-group-type="author">
<name>
<surname><![CDATA[Bustamante Bozzo]]></surname>
<given-names><![CDATA[R]]></given-names>
</name>
<name>
<surname><![CDATA[Lacassie Quiroga]]></surname>
<given-names><![CDATA[HJ]]></given-names>
</name>
</person-group>
<article-title xml:lang=""><![CDATA[Manejo anestésico de la paciente de urgencia embarazada]]></article-title>
<source><![CDATA[Rev chil anest]]></source>
<year>2021</year>
<volume>50</volume>
<numero>1</numero>
<issue>1</issue>
<page-range>171-95</page-range></nlm-citation>
</ref>
</ref-list>
</back>
</article>
