title: Inadvertent intrathecal injection of large dose magnesium sulfate.
abstract: The case is a 35-year-old man who underwent spinal anesthesia for emergency strangulated inguinal hernia repair. About five minutes after 3 ml intrathecal drug injection, the patient suffered respiratory distress, bradycardia, hypotension and loss of consciousness. The patient was rapidly intubated and crystalloid infusion and epinephrine drip were established. Thereafter, he was admitted in intensive care unit. Search for the cause revealed us that 3 ml of magnesium sulfate (50%) was injected mistakenly for spinal anesthesia. Two days later, he was extubated and on the fifth day, he was discharged from the hospital without an obvious evidence of complication.
authors.affiliation: Department of Anesthesiology and Critical Care, Tehran University of Medical Sciences, Sina Hospital, Tehran, Iran.
authors.forename: Atabak
authors.initials: A
authors.lastname: Najafi
authors.affiliation: Department of Anesthesiology and Critical Care, Tehran University of Medical Sciences, Sina Hospital, Tehran, Iran.
authors.forename: Hooshang
authors.initials: H
authors.lastname: Akbari
authors.affiliation: Department of Anesthesiology and Critical Care, Tehran University of Medical Sciences, Sina Hospital, Tehran, Iran.
authors.forename: Mohammad Reza
authors.initials: MR
authors.lastname: Khajavi
authors.affiliation: Department of Anesthesiology and Critical Care, Tehran University of Medical Sciences, Sina Hospital, Tehran, Iran.
authors.forename: Farhad
authors.initials: F
authors.lastname: Etezadi
keywords: Inadvertent intrathecal injection; magnesium sulfate; neurotoxicity; spinal anesthesia