Accidental intrathecal injection of aminophylline in spinal anesthesia.

M EDICATION error has been an unfortunate chapter in the history of spinal anesthesia since its invention in 1899. Many catastrophic incidents have occurred from intrathecal injection of local anesthetics contaminated with other chemicals as well as the use of drugs not intended or approved for intrathecal administration. In such situations, patient outcomes depend on the nature of the contaminant or the drug effects. Outcomes range from transient neurologic symptoms to permanent neurologic damage, including paraplegia. Although there are reports on a wide variety of medication errors in spinal anesthesia, accidental intrathecal use of aminophylline, a bronchodilator, has not been described previously.