This case report highlights the rehabilitation outcomes of a 24-year-old female who received inadvertent intrathecal digoxin during a routine cesarean section, leading to encephalomeningitis, vestibulocochlear neuritis, and incomplete paraplegia. Despite initial neurological deficits, the patient demonstrated significant improvement in both cognition and functional mobility during a one-month inpatient rehabilitation program, ultimately achieving ambulation with assistive devices. This case underscores the potential for rehabilitation of neurological sequela following accidental intrathecal digoxin administration.
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| http://www.ncbi.nlm.nih.gov/pmc/articles/PMC11344593 | PMC |
| http://dx.doi.org/10.7759/cureus.65376 | DOI Listing |
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This case report highlights the rehabilitation outcomes of a 24-year-old female who received inadvertent intrathecal digoxin during a routine cesarean section, leading to encephalomeningitis, vestibulocochlear neuritis, and incomplete paraplegia. Despite initial neurological deficits, the patient demonstrated significant improvement in both cognition and functional mobility during a one-month inpatient rehabilitation program, ultimately achieving ambulation with assistive devices. This case underscores the potential for rehabilitation of neurological sequela following accidental intrathecal digoxin administration.
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Article Synopsis
- The review examines inadvertent cardiovascular medication errors during neuraxial procedures over the past 50 years, focusing on their prevalence, harm, and clinical consequences.
- It highlights that these errors often involve drugs like digoxin and ephedrine, with many resulting in serious health issues, including permanent neurological deficits in some patients.
- The analysis identifies key contributing factors to these errors, such as inadequate training for junior doctors and poor organizational practices, and recommends targeted safety strategies to prevent future incidents.
Intrathecal administration of digoxin occurs very rarely. Some case reports of inadvertently administering it when performing spinal/epidural anesthesia were described. We report for the first time a case of a chemical meningitis and status epilepticus caused by accidental epidural administration of digoxin.
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