Abstract Introduction Tranexamic acid (TXA) is a widely used antifibrinolytic agent to reduce perioperative bleeding. When administered intravenously, it is generally safe, but intrathecal administration is rare and can result in severe neurotoxicity. Reported complications include seizures, myoclonus, encephalopathy, and cardiovascular instability. We present a case of accidental intrathecal TXA administration leading to life-threatening neurological injury and discuss key management considerations. Case Presentation A 74-year-old male with hypertension and hyperlipidemia underwent elective right total hip arthroplasty. During the procedure, 250 mg of TXA was inadvertently injected intrathecally instead of the intended spinal anesthetic. Following surgery, the patient failed to regain consciousness and developed fixed, non-reactive pupils with generalized myoclonic jerking. He was intubated and transferred to our institution for further management. Upon arrival, his blood pressure was 194/88 mmHg and heart rate was 115 bpm. Arterial blood gas revealed metabolic acidosis (pH 7.29). Head CT angiography, and brain MRI showed no acute structural abnormalities. Continuous EEG monitoring demonstrated frequent myoclonic jerks without electrographic seizures. Sedation with propofol and midazolam was initiated, resulting in gradual reduction of abnormal movements. Supportive care was continued in the ICU. By hospital day 5, the patient demonstrated improving neurological responsiveness and was successfully extubated. He was transferred to a rehabilitation facility to continue recovery. Discussion TXA-induced neurotoxicity is thought to occur through antagonism of GABA-A and glycine receptors, which normally inhibit neuronal excitation. Blocking these receptors lowers the threshold for neuronal depolarization, leading to uncontrolled neuronal firing and myoclonus. Reduced cerebral blood flow may further exacerbate excitotoxic injury. Early airway protection, continuous EEG monitoring, and sedation to restore inhibitory tone are central to management. This case also underscores the importance of careful medication labeling, verification, and communication in the operative environment to prevent similar medication errors. Conclusion Accidental intrathecal TXA administration is a rare but life-threatening event that requires prompt recognition and aggressive supportive care. Clinicians should maintain vigilance during medication preparation and administration, particularly in operative settings where TXA is frequently used. Strengthening safety protocols may prevent similar occurrences and improve patient outcomes. This abstract is funded by: None
Qasarweh et al. (Fri,) studied this question.