labetalol , a combined alfa and beta - adrenergic receptor antagonist , is an antihypertensive drug frequently used to treat systemic hypertension in acute care settings , including in obstetrics .
we present an unusual case characterized by a rise in blood pressure ( bp ) , rather than hypotension , and temporary neural dysfunction following inadvertent intrathecal administration of labetalol during obstetric anesthesia .
a 25-year - old woman , parity status p1 + 0 , weighing 50 kg , presented in early labor at term with a history of loss of fetal movement and cesarean section in the earlier pregnancy . on admission , she was fully oriented with a pulse rate of 80/min and bp of 130/70 mmhg , and the fetal heart sounds were equivocal .
she was put up for emergency lower segment cesarean section under spinal anesthesia and premedicated with ranitidine 50 mg by intramuscular ( i m ) route and metoclopramide 10 mg i m in the labor room before being brought into the operation theater ( ot ) . in the ot , her vitals were taken which showed pulse 76/min , bp 140/72 mmhg , and oxygen saturation 98% in room air .
intravenous ( iv ) cannulation was done with an 18 g cannula and ringer lactate infusion started .
spinal anesthesia was administered , in the sitting posture , at the l2-l3 interspace with a 25 g quincke 's spinal needle by the anesthesia junior resident .
the intended drug was hyperbaric bupivacaine 0.5% w / v , and the volume administered was 2.6 ml . immediately upon assuming the supine position , the patient started complaining of acute pain in both lower limbs along with intense burning sensation .
the situation was rescued by converting to general anesthesia by propofol 100 mg iv , intubating with the help of succinylcholine 50 mg iv and maintaining with nitrous oxide 60% and oxygen 40% inhalation .
muscle relaxation was continued with atracurium 25 mg iv in two divided doses ( 20 mg + 5 mg ) .
the cesarean section was completed without problems and a 2.4 kg live baby was delivered .
relaxation was reversed by neostigmine 2.5 mg iv with glycopyrrolate 400 mcg iv , and nitrous oxide was withdrawn after recovery of spontaneous respiration .
the patient was extubated uneventfully and did not complain of any further leg pain or burning sensation after recovery from anesthesia .
vital signs remained normal postoperatively , and the patient was shifted to the postnatal ward .
the case was not reported to the hospital administration as there is no system of medication error reporting in the institution .
the mix - up had occurred in picking up the vial from the anesthetic injection tray on which multiple ampoules and vials were kept .
an intern had picked up the ampoule , broken the top and held it while the resident drew up the injection in the syringe without reading the label .
the ampoules [ figure 1 ] were similar in size and amber colored although the labeling was distinct .
the ampoule of labetalol from which the injection was drawn shown side by side with an ampoule of spinal bupivacaine from which it should have been drawn .
they are similar in appearance though labeling is distinct a medication error is any failure in the medicine selection , prescription , dispensing , handling , and use process that may harm the patient .
like adverse drug reactions ( adrs ) , medication errors are an inevitable consequence of pharmacotherapy , although , unlike adrs , they are often preventable through individual and institutional measures . though recognized as an important cause of patient mortality and morbidity globally , particularly in operative , emergency , critical care , and other such high pill burden settings , medication errors remain a neglected phenomenon in india , particularly in public hospital context .
it may be related to professional practice , products , procedures , environment or systems ; may involve prescribing and ordering ; dispensing and distribution ; preparation and administration ; labeling , packaging , and nomenclature ; communications and education ; or use and monitoring of treatment .
commonly implicated are medication factors ( e.g. , similar sounding names , low therapeutic index , polypharmacy ) , patient factors ( e.g. , impaired cognition , vision problems and other physical disabilities , poor renal or hepatic function ) or health system - related factors ( e.g. , use of inappropriate abbreviations and decimal points on prescriptions , failure to read drug labels , overburdening , and fatigue of healthcare providers ) . in our case , the reasons were keeping similar looking ampoules together , failure on the part of the intern to read the label and failure on the part of the resident to cross - check that the correct medication was being injected .
labetalol is a dual alfa - and beta - adrenergic antagonist that is often used to treat systemic hypertension in acute care settings .
iv overdose of labetalol has been reported to cause hypotension and bradycardia as would be expected from the receptor profile of its activity .
therefore , the acute rise of bp , tachycardia , and the intense pain and burning are difficult to explain .
theoretically , the unopposed beta - adrenergic blockade can lead to rise in bp by peripheral vasoconstriction mediated through alfa1-adrenergic receptors on vascular smooth muscle .
however , this is not expected of labetalol since it simultaneously blocks alfa - receptors .
nevertheless , the network of neurotransmission in the central neuraxis is complex and it is possible that a large dose of labetalol may have unexpected receptor activity ( for instance blockade of central alfa2-autoreceptors will increase noradrenaline release from adrenergic synapses ) that transiently caused these events .
finally , it is to be noted that a system of medication error reporting does not exist in this hospital , or for that matter , most hospitals in india , and this may lead to such events recurring in future . introducing such a system can be worthwhile and would be an important step toward assessing and reducing the medication error burden .
unfortunately , we anticipate that any attempt at the introduction of such a system would be met by resistance out of fear of being identified and subsequently penalized for negligence .
two approaches to human error have been described : ( 1 ) the person approach and ( 2 ) the systems approach and they are also applicable to the issue of medication errors .
the systems approach accepts that humans are fallible , and therefore , errors may occur regardless of the competence of individuals working within the system .
rather than focusing on the individual , it focuses on the conditions under which individuals work and how those conditions can predispose to errors .
it is now widely acknowledged that although professionals must take responsibility for their actions , blaming doctors , pharmacists , or nurses for errors does not encourage a culture of reporting or learning .
serious errors are often caused by wider defects in the system that lie dormant ( latent conditions ) until they combine with human error to precipitate a serious incident . in order to reduce risk ,
a system needs to understand its defects so that it can minimize them by building appropriate defenses and safeguards .
defects can only be identified if there is a commitment to an open culture of reporting throughout the system .
 labetalol , a combined alfa and beta - adrenergic receptor antagonist , is used as an antihypertensive drug . 
 we report a case of an acute rise in blood pressure and lower limb pain due to the inadvertent intrathecal administration of labetalol , mistaking it for bupivacaine , during obstetric anesthesia . 
 the situation was rescued by converting to general anesthesia . 
 the cesarean delivery was uneventful , and mother as well as newborn child showed no ill - effect . 
 this particular medication error was attributable to a failure on the part of the doctors administering the injection to read and cross - check medication labels and the practice of keeping multiple injections together . in the absence of an organized medication error reporting system and action on that basis 
 , such events may recur in future . 
Introduction
Case Report
Discussion
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