Accidental Intrathecal Injection of Nilperidol® in Spinal Anesthesia. Case Report

Some factors have been identiϐied as contributing to medical errors such as labels, appearance, and location of ampoules. This report relates how droperidol associated with fentanyl (Nilperidol®) was given by mistake, intrathecally, during spinal anesthesia, to a 72-year-old man, who was a candidate for rectosigmoidectomy with an ileostomy. When checking the ampoules used in spinal anesthesia, an error in the administration of droperidol along with fentanyl was noted. When preparing for general anesthesia, severe arterial hypotension occurred, which did not respond to the ephedrine injection. The use of norepinephrine was required but it was removed before extubation in the operating room. Upon entering PACU, he reported grade 8 pains, and morphine was administered. The patient remained in the PACU for 2 hours and was referred to the inϐirmary without complaints, remaining conscious throughout the period. The patient was followed up by the Anesthesia Service until hospital discharge, which occurred after three days, without complaints or complications related to anesthesia. There was not any nervous disturbance observed within the week of follow-up.

Keywords: Accidental injection, Intrathecal opioids injection, Spinal anesthesia, Droperidol.

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