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Various toxicities following medication errors: 7 case reports A 51-year-old man developed CNS and cardiovascular disorders after inadvertently receiving a baclofen overdose and 60-year-old woman developed tetraplegia following intrathecal administration of methylthioninium chloride [methylene blue]; the woman later died. These 2 cases were among 7 reports of medication errors involving intrathecal administration reported to a German poisons information centre between 1999–2008 [details not provided for the remaining cases]. All 7 cases occurred in adults; three involved morphine, three involved baclofen and one involved methylthioninium chloride. Five cases reported inadvertent drug overdoses and 1 case detailed intrathecal, instead of epidural, administration of morphine. The man developed impaired consciousness, hallucinations, hypotension, sinus bradycardia, dyspnoea and flushing around 1 hour after receiving an accidental baclofen overdose (0.06 mg/kg) [therapeutic indication not stated]. He was admitted to an ICU. Liquor was drawn to reduced the baclofen concentration in the CSF and he was intubated for ventilatory support for 48 hours. His cardiovascular symptoms responded to treatment with atropine, dobutamine and dopamine. Four days later, he was discharged from the ICU and recovered without sequelae. Within a few hours of intrathecal injection of methylthioninium chloride [dosage not stated] during a diagnostic procedure, the woman developed paraplegia that progressed to tetraplegia. The onset of respiratory failure led to her intubation. Extended intermedullary signal enhancement in the whole spinal cord was evident on MRI, continuing up to the medulla oblongata. The liquor appeared blue in colour with a markedly elevated protein level. She was treated with methylprednisolone and the lumbar liquor was drained. Subsequently, she had no brainstem reflexes and died 6 days later. Prasa D, et al. Medication errors in intrathecal application: a rare but severe occurrence. 9th Annual Meeting of the International Society of Pharmacovigilance 801152320 : abstr. 21, 6 Oct 2009 [abstract] - Germany

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Reactions 9 Jan 2010 No. 1283