title: Survival after intravenous thrombin prior to cardiopulmonary bypass.
abstract: We present a case of a patient undergoing aortic valve replacement being inadvertently administered 5000 U of bovine thrombin instead of heparin for anticoagulation for cardiopulmonary bypass. The labeling error was made within the operating room pharmacy. The key to survival of this patient was a rapid diagnosis, administration of antithrombin and heparin, and removal of cardiac and great vessel thrombi. It is recommended that point of care anesthesia providers `prepare heparin for cardiopulmonary bypass anticoagulation, as thrombin is not used in anesthetic practice and is not contained within anesthesia cabinet medication drawers.
authors: The Department of Anesthesiology, University of Arizona College of Medicine, 1501 North Campbell Avenue, P.O. Box 245114, 85724-5114, Tucson, AZ, USA. vnielsen@anesth.arizona.edu.
authors: Vance G
authors: VG
authors: Nielsen
authors: The Department of Anesthesiology, University of Arizona College of Medicine, 1501 North Campbell Avenue, P.O. Box 245114, 85724-5114, Tucson, AZ, USA.
authors: Samata R
authors: SR
authors: Paidy
authors: The Department of Anesthesiology, University of Arizona College of Medicine, 1501 North Campbell Avenue, P.O. Box 245114, 85724-5114, Tucson, AZ, USA.
authors: Camron A
authors: CA
authors: Meek
authors: The Department of Anesthesiology, University of Arizona College of Medicine, 1501 North Campbell Avenue, P.O. Box 245114, 85724-5114, Tucson, AZ, USA.
authors: Tiffany K
authors: TK
authors: Thornton
authors: The Department of Surgery, University of Arizona College of Medicine, Tucson, AZ, USA.
authors: Scott D
authors: SD
authors: Lick
mesh_terms: D000368:Aged; D002315:Cardiopulmonary Bypass; D005260:Female; D006490:Hemostatics / Q000008:administration & dosage / Q000009:adverse effects*; D006801:Humans; D008508:Medication Errors; D011292:Premedication; D013917:Thrombin / Q000008:administration & dosage / Q000009:adverse effects*
chemical_list: D006490:Hemostatics; D013917:Thrombin
keywords: Antithrombin; Cardiopulmonary bypass; Heparin; Medication error; Thrombin