Inadvertent Intrathecal Administration of Digoxin, with Review of the Literature

While the systemic effects of digoxin have been studied, limited data exist on the effects of neuraxial administration. Prior case reports document how digoxin and lidocaine share indistinguishable vials and were inadvertently stocked together in spinal and epidural anesthesia kits, necessitating a...

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Main Authors: Burton J. Tabaac, Ian O. T. Laughrey, Hany F. Ghali
Format: Article
Language:English
Published: Wiley 2023-01-01
Series:Case Reports in Neurological Medicine
Online Access:http://dx.doi.org/10.1155/2023/4034919
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author Burton J. Tabaac
Ian O. T. Laughrey
Hany F. Ghali
author_facet Burton J. Tabaac
Ian O. T. Laughrey
Hany F. Ghali
author_sort Burton J. Tabaac
collection DOAJ
description While the systemic effects of digoxin have been studied, limited data exist on the effects of neuraxial administration. Prior case reports document how digoxin and lidocaine share indistinguishable vials and were inadvertently stocked together in spinal and epidural anesthesia kits, necessitating a need for further implementation of safety measures. Here, we report the poor progression and brain death of a postpartum woman after accidental administration of intrathecal digoxin during a routine elective cesarean section (C-section). It is imperative that quality improvement and safety measures are taken to avoid the recurrence of this medical error.
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spelling doaj-art-b32b7b6d45be47378ea38c2ce25c17092025-08-20T02:23:27ZengWileyCase Reports in Neurological Medicine2090-66762023-01-01202310.1155/2023/4034919Inadvertent Intrathecal Administration of Digoxin, with Review of the LiteratureBurton J. Tabaac0Ian O. T. Laughrey1Hany F. Ghali2University of Nevada, RenoUniversity of Nevada, RenoDepartment of Intensive CareWhile the systemic effects of digoxin have been studied, limited data exist on the effects of neuraxial administration. Prior case reports document how digoxin and lidocaine share indistinguishable vials and were inadvertently stocked together in spinal and epidural anesthesia kits, necessitating a need for further implementation of safety measures. Here, we report the poor progression and brain death of a postpartum woman after accidental administration of intrathecal digoxin during a routine elective cesarean section (C-section). It is imperative that quality improvement and safety measures are taken to avoid the recurrence of this medical error.http://dx.doi.org/10.1155/2023/4034919
spellingShingle Burton J. Tabaac
Ian O. T. Laughrey
Hany F. Ghali
Inadvertent Intrathecal Administration of Digoxin, with Review of the Literature
Case Reports in Neurological Medicine
title Inadvertent Intrathecal Administration of Digoxin, with Review of the Literature
title_full Inadvertent Intrathecal Administration of Digoxin, with Review of the Literature
title_fullStr Inadvertent Intrathecal Administration of Digoxin, with Review of the Literature
title_full_unstemmed Inadvertent Intrathecal Administration of Digoxin, with Review of the Literature
title_short Inadvertent Intrathecal Administration of Digoxin, with Review of the Literature
title_sort inadvertent intrathecal administration of digoxin with review of the literature
url http://dx.doi.org/10.1155/2023/4034919
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AT ianotlaughrey inadvertentintrathecaladministrationofdigoxinwithreviewoftheliterature
AT hanyfghali inadvertentintrathecaladministrationofdigoxinwithreviewoftheliterature