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LETTER TO THE EDITOR

Accidental Intrathecal Administration of Digoxin

Department of Anesthesia, Yahyanejad Hospital, Babol University of Medical Sciences, Babol, Iran, rsaghebi{at}yahoo.com

To the Editor:

An 80-kg, 21-yr-old ASA physical status I male was admitted for thrombotic hemorrhoidectomy. He underwent spinal anesthesia with 1 mL of 5% lidocaine (1). No block resulted, necessitating conversion to general anesthesia. The patient’s hemodynamics remained stable throughout anesthesia, surgery, and recovery.

Two hours after surgery, he complained of paraesthesias and paralysis of his lower limbs up to the umbilical level. He was conscious but agitated, tachycardic, and hypertensive. We noticed abdominal distension and urinary retention. Lower limb reflexes were absent. Clinical examination and chest radiograph, electrocardiogram, electroencephalogram, and head computed tomography were otherwise normal. By 24 h after surgery motor strength, sensory function, and spinal reflexes in the lower limbs were normal. The patient was discharged 48 h after surgery, and follow-up over 5 mo did not identify any sequelae.

Two similar incidents occurred over the next month in the same operating room. Investigation revealed that digoxin had been accidentally intermixed with 5% lidocaine in the operating room drug reservoir, owing to nearly indistinguishable vials (Fig. 1). The likely explanation for all three cases is intrathecal administration of 0.5 mg digoxin.

View larger version (166K): [in this window] [in a new window]   Figure 1. Indistinguishable vials.

Cardiac glycosides inhibit Na⁺/K⁺ adenosine triphosphatase (2). We surmise that 0.5 mg digoxin in the intrathecal space transiently blocked all Na pumps, resulting in reversible loss of neural conduction. This experience is consistent with other reports suggesting that the onset of anesthesia and analgesia after 2 h is suggestive of a spinal anesthesia with a drug rather than common local anesthetics (3–8).

References

1. Miller R. Anesthesia, New York: Churchill Livingstone, 2005:1653–70.
2. Katzung BG. Basic and clinical pharmacology, 8th ed. 2001:205–6.
3. Mihic DN. Post spinal headache and relationship of needle bevel to longitudinal dural fibers. Reg Anaesth 1985;10:76.
4. Thornberry EA, Thomas TA. Posture and post-spinal headache: a controlled trial in 80 obstetrics patients. Br J Anaesth 1988;60:195–7.[Abstract/Free Full Text]
5. Brown EM, Elman DS. Postoperative backache. Anesth Analg 1961;40:683–5.[Web of Science]
6. Green NM. Physiology of spinal anesthesia, 3rd ed. Baltimore: Williams and Wilkins, 1981.
7. Breadsly D, Holman S, Gantt R. Transient neurological deficit after spinal anesthesia: local anesthetic maldistribution with pencil-point needle. Anesth Analg 1995;81:314–20.[Abstract]
8. Douglas MJ. Neurotoxicity of lidocaine-does it exist? Can J Anaesth 1995;42:181–5.[Web of Science][Medline]

This article has been cited by other articles:

				P.-A. Maleh, S. M. Reza-Hashemian, G. Sharifi, and A.-A. Asgari Intrathecal Administration of Digoxin in Rabbits Anesth. Analg., February 1, 2007; 104(2): 469 - 469. [Full Text] [PDF]

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