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Anesthetic Pharmacology
Anesthesia and Pain Medicine 2013;8(1):26-29.
Published online January 31, 2013.
Inadvertent intrathecal dobutamine administration and barbiturate induced nystagmus: A case report
In Yeob Baek, Ji Uk Yoon, Hyun Jun Cho, Nam Won Kim, Gyeong Jo Byeon, Hyae Jin Kim
Department of Anesthesiology and Pain Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea. jiuk@pusan.ac.kr
Abstract
Medication errors remain an unsolved problem in medicine. Some factors have been found to contribute to drug errors, and among them, the incorrect administration of drugs is a major factor. In this case report, 2 ml of dobutamine was inadvertently injected intrathecally instead of bupivacaine owing to ampoule confusion during spinal anesthesia, followed by the induction of general anesthesia with sodium thiopental-sevoflurane. It was uneventful during perioperative period, however, nystagmus was observed in post anesthesia care unit (PACU), about 1 h after induction of general anesthesia. There were no other neurologic abnormalities except nystagmus and vital sign were stable during PACU stay. Nystagmus subsided spontaneously and it was confirmed there was no evidence of any central nervous system lesion on imaging study. The patient was discharged 5 days later without any complications.
Key Words: Accidental, Dobutamine, Intrathecal, Medication errors, Nystagmus


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