Accidental Intrathecal Injection of Atracurium During Spinal Anesthesia: A Case Report

Abstract

This case report outlines a rare occurrence of accidental intrathecal injection of atracurium during spinal anesthesia for knee arthroscopy in a 22-year-old male patient. The solution intended to be bupivacaine mixed with fentanyl raised concerns after the ampule was discarded before verification. Fortunately, the patient showed no signs of paralysis or analgesia post-injection. The anesthesia team promptly administered high-dose methylprednisolone to reduce potential neurotoxic effects and monitored the patient closely in the Post-Anesthesia Care Unit. After six hours of stability and no neurological deficits, follow-up evaluations confirmed no lasting damage, allowing for safe discharge after 24 hours. This incident underscores the critical need for rigorous drug verification and safety protocols in anesthesia to prevent medication errors.