Inadvertent administration of intrathecal protamine during caesarian section

Abstract

A pregnant lady was planned to undergo an elective cesarean section under spinal block. After routine monitoring a trainee resident performed the block under the consultant supervision. As per standard practice, the Operating Department Practitioner (ODP) read aloud the contents of ampoule as bupivacaine, the trainee resident voiced the same and gestured to read the label and proceeded to inject the solution into the subarachnoid space. The consultant moved forward to check the ampoule when he noticed that the ampoule actually read Protamine and not bupivacaine. Meanwhile the resident had injected nearly 1.5 ml of the solution. The procedure was abandoned; surgeon informed and patient was sensitively informed of the error. Patient’s vital signs and cardiotocography (CTG) were observed closely, first in the theatre and then in the recovery area. She was watched for any signs of dyspnea, rashes or syncope. Her vitals remained stable, no untoward signs and symptoms were noted and patient was discharged after four hours from recovery area. Patient was examined by anesthesia team in the obstetric ward after 24 hours and found to be entirely non symptomatic and without any new abnormal physical finding. Subsequently, she had another spinal performed and had a normal baby was delivered.