Accidental intrathecal injection of dopamine hydrochloride resulting in analgesic effects

provided the original work is properly cited. CC Medication errors are defined as any error in the delivery process, whether there are any adverse consequences or not [1]. In the present case report, we describe an accidental intrathecal injection of dopamine hydrochloride (DA) which has not been previously reported in human. We were blinded to the fact due to the analgesic and anesthetic effects that seemed to have been achieved after the injection of DA. A 76 year-old man was scheduled for closed reduction and internal fixation of an intertrochanteric fracture of the right femur. His medical history included diabetes mellitus, hypertension and chronic renal failure with maintenance hemodialysis for the last 4 years. The blood glucose level was with 95–337 mg/ dl and the blood pressure (BP) with 140–200/80–100 mmHg poorly controlled. The preoperative pulmonary function test revealed a severe restrictive respiratory disorder. We decided to apply a spinal anesthesia for his operation. Electrocardiogram, BP, heart rate (HR) and arterial hemoglobin oxygen saturation were measured after the patient was brought to the operating room. The BP was 160/80 mmHg and the HR showed 95 beats/min. A spinal anesthesia was performed at the L3-4 interspace with the patient in a left lateral position using a 25-gauge Quinke tip needle. The drug ampule assumed to content of 0.5% bupivacaine hydrochloride (20 mg/4 ml, Hana Pharm, Seoul, Korea) was passed by the nurse and 2.0 ml of drug was injected into the intrathecal space. Five minutes later, he was not able to sense cold sensation (alcohol swab) and pain (blunt needle) below T10 level and the surgery began. After skin incision, the patient seemed comfortable and the vital signs remained constant except a slight increase in BP with around 170/90 mmHg. In 30 minutes after incision, he complained of mild pain at the incision site. Shortly after, the nurse noticed that 80 mg of DA (200 mg/5 ml, Hana Pharm, Seoul, Korea) had been drawn and intrathecally injected instead of 0.5% bupivacaine (Fig. 1). 80 mg propofol was intravenously administered and a laryngeal mask airway (LMA) was inserted. Anesthesia was maintained using 0.5–1.0 MAC sevoflurane. We performed an arterial cannulation at the left radial artery and continuously monitored the arterial pressure. After induction