Accidental Intrathecal Injection of Atracurium During Spinal Anesthesia: A Case Report

Padideh  Ansar; Neda  Tadjeddin; Hamideh  Ariannia; Faranak  Behnaz; Seyedpouzhia  Shojaei

doi:10.18502/aacc.v12i2.20963

Padideh Ansar Department of Anesthesiology, Shohada Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
Neda Tadjeddin Department of Anesthesiology, Shohada Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
Hamideh Ariannia Department of Anesthesiology, Shohada Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
Faranak Behnaz Department of Anesthesiology, Shohada Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
Seyedpouzhia Shojaei Department of Anesthesiology, Shohada Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.

DOI: https://doi.org/10.18502/aacc.v12i2.20963

Keywords: Atracurium; Intrathecal injection; Spinal anesthesia; Human error; Neuromuscular blockade; Patient safety

Abstract

This case report outlines a rare occurrence of accidental intrathecal injection of atracurium during spinal anesthesia for knee arthroscopy in a 22-year-old male patient. The solution intended to be bupivacaine mixed with fentanyl raised concerns after the ampule was discarded before verification. Fortunately, the patient showed no signs of paralysis or analgesia post-injection. The anesthesia team promptly administered high-dose methylprednisolone to reduce potential neurotoxic effects and monitored the patient closely in the Post-Anesthesia Care Unit. After six hours of stability and no neurological deficits, follow-up evaluations confirmed no lasting damage, allowing for safe discharge after 24 hours. This incident underscores the critical need for rigorous drug verification and safety protocols in anesthesia to prevent medication errors.