Tranexamic acid at cesarean delivery: drug-error deaths - 22/12/22

Doi : 10.1016/j.ajog.2022.05.072

Neil F. Moran, BM, BCh, MA (Cantab), FCOG (SA) ^a,^b, David G. Bishop, MB, ChB, FCA (SA), PhD ^a,^c, Susan Fawcus, MB, BCh, MA (Oxon.), FRCOG ^d, Edward Morris, MBBS, BSc, MD, FHEA, FRCOG ^e, Haleema Shakur-Still, RN, PhD ^f, Adam J. Devall, BMedSci, PhD ^g, Ioannis D. Gallos, MB, ChB, MD ^h, Mariana Widmer, MSc ^h, Olufemi T. Oladapo, MD ^h, Arri Coomarasamy, MB, ChB, MD ^g,^⁎ , G. Justus Hofmeyr, DSc ^i,^j,^k
^a KwaZulu-Natal Department of Health, South Africa
^b Department of Obstetrics and Gynaecology, University of KwaZulu-Natal, Durban, South Africa
^c Department of Anaesthesia, University of KwaZulu-Natal, Durban, South Africa
^d Department of Obstetrics and Gynaecology, University of Cape Town, Cape Town, South Africa
^e Department of Obstetrics and Gynaecology, Norfolk and Norwich University Hospital, Norwich, United Kingdom
^f London School of Hygiene & Tropical Medicine, London, United Kingdom
^g World Health Organization Collaborating Centre for Global Women’s Health, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
^h UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
ⁱ Department of Obstetrics and Gynecology, University of Botswana, Gaborone, Botswana
^j Effective Care Research Unit, University of the Witwatersrand, Johannesburg, South Africa
^k Department of Obstetrics and Gynecology, Walter Sisulu University, Mthatha, South Africa

^∗Corresponding author: Arri Coomarasamy, MB, ChB, MD.

Abstract

The use of tranexamic acid for postpartum hemorrhage has entered obstetrical practice globally with the evidence-based expectation of saving lives. This improvement in the care of women with postpartum hemorrhage has come at a price. For the anesthetist, having tranexamic acid ampoules close at hand would seem an obvious strategy to facilitate its use during cesarean delivery, an important setting for severe hemorrhage. Tragically, we have identified a number of recent instances of inadvertent intrathecal administration of tranexamic acid instead of local anesthetic for spinal anesthesia. Reported cases of this catastrophic error seem to be increasing. The profound neurotoxicity of tranexamic acid causes rapid-onset convulsions, with mortality of 50%.

How can these tragic errors be averted? Drug safety alerts have been issued by the US Food and Drug Administration and the World Health Organization, but that is not enough. We recommend extensive dissemination of information to raise awareness of this potential hazard, and local hospital protocols to ensure that tranexamic acid is stored separately from anesthetic drugs, preferably outside the operating room and with an auxiliary warning label. Implementation of safety strategies on a very large scale will be needed to ensure that the life-saving potential of tranexamic acid is not eclipsed by drug-error mortality.

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Key words : cesarean delivery, drug administration error, postpartum hemorrhage, spinal anesthesia, tranexamic acid

	This article is being published simultaneously in the International Journal of Gynecology & Obstetrics, BJOG: An International Journal of Obstetrics & Gynaecology, the American Journal of Obstetrics & Gynecology, and the European Journal of Obstetrics & Gynecology and Reproductive Biology.
	The authors report no conflict of interest.
	No funding was received for this paper.