Medication error report: Intrathecal administration of labetalol during obstetric anesthesia.
Labetalol, a combined alfa and beta-adrenergic receptor antagonist, is used as an antihypertensive drug. We report a case of an acute rise in blood pressure and lower limb pain due to the inadvertent intrathecal administration of labetalol, mistaking it for bupivacaine, during obstetric anesthesia. The situation was rescued by converting to general anesthesia. The cesarean delivery was uneventful, and mother as well as newborn child showed no ill-effect. This particular medication error was attributable to a failure on the part of the doctors administering the injection to read and cross-check medication labels and the practice of keeping multiple injections together. In the absence of an organized medication error reporting system and action on that basis, such events may recur in future.
Department of Anesthesiology, Midnapore Medical College and Hospital, Midnapur, West Bengal, India.
Baisakhi
B
Laha
Department of Pharmacology, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India.
Avijit
A
Hazra
D000319:Adrenergic beta-Antagonists / Q000008:administration & dosage / Q000009:adverse effects*; D000328:Adult; D000773:Anesthesia, Obstetrical / Q000009:adverse effects*; D000779:Anesthetics, Local / Q000008:administration & dosage; D001794:Blood Pressure / Q000187:drug effects; D002045:Bupivacaine / Q000008:administration & dosage; D002585:Cesarean Section; D005260:Female; D006801:Humans; D007278:Injections, Spinal; D007741:Labetalol / Q000008:administration & dosage / Q000009:adverse effects*; D008508:Medication Errors; D011247:Pregnancy
D000319:Adrenergic beta-Antagonists; D000779:Anesthetics, Local; D007741:Labetalol; D002045:Bupivacaine
Bupivacaine; labetalol; medication error; spinal anesthesia