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International Journal of Legal Medicine
Erschienen in:

22.10.2016 | Case Report

Survival after intravenous thrombin prior to cardiopulmonary bypass

verfasst von: Vance G. Nielsen, Samata R. Paidy, Camron A. Meek, Tiffany K. Thornton, Scott D. Lick

Erschienen in: International Journal of Legal Medicine | Ausgabe 2/2017

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Abstract

We present a case of a patient undergoing aortic valve replacement being inadvertently administered 5000 U of bovine thrombin instead of heparin for anticoagulation for cardiopulmonary bypass. The labeling error was made within the operating room pharmacy. The key to survival of this patient was a rapid diagnosis, administration of antithrombin and heparin, and removal of cardiac and great vessel thrombi. It is recommended that point of care anesthesia providers `prepare heparin for cardiopulmonary bypass anticoagulation, as thrombin is not used in anesthetic practice and is not contained within anesthesia cabinet medication drawers.
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Santell JP (2006) Technological methods used to prevent errors aren’t infallible. Mater Manag Health Care 15:26–28PubMed
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Hanna GM, Levine WC (2011) Medication safety in the perioperative setting. Anesthesiol Clin 29:135–144CrossRefPubMed
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Uchigasaki S, Takahashi H, Suzuki T (1998) A case of delayed death after accidental intravenous injection of thrombin. Int J Legal Med 111:202–204CrossRefPubMed
Metadaten
Titel
Survival after intravenous thrombin prior to cardiopulmonary bypass
verfasst von
Vance G. Nielsen
Samata R. Paidy
Camron A. Meek
Tiffany K. Thornton
Scott D. Lick
Publikationsdatum
22.10.2016
Verlag
Springer Berlin Heidelberg
Erschienen in
International Journal of Legal Medicine / Ausgabe 2/2017
Print ISSN: 0937-9827
Elektronische ISSN: 1437-1596
DOI
https://doi.org/10.1007/s00414-016-1480-7

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