Accidental intrathecal injection of high-dose magnesium sulphate with conventional-dose bupivacaine: a case report.

BACKGROUND

Although inadvertent intrathecal injection of medications is rare, it often leads to catastrophic neurological complications. This report describes a case of accidental intrathecal injection of high-dose magnesium sulphate combined with a local anaesthetic during anaesthesia for orthopaedic surgery, aiming to raise clinical awareness of safety regarding drug administration routes.

CASE DESCRIPTION: An 80-year-old female patient underwent emergency spinal anaesthesia for surgical repair of a left femoral neck fracture. Due to the inadvertent addition of magnesium sulphate to bupivacaine for intrathecal administration, the patient developed acute hypotension and bradycardia, requiring vasopressor support to maintain circulation. Postoperatively, she exhibited lethargy, persistent hypotension, fever, decreased upper limb muscle strength, and complete paralysis of both lower limbs. Following symptomatic management, her condition gradually improved: hemodynamic stability was restored within 24 hours, and complete recovery of consciousness, motor, and sensory functions to preoperative baseline levels was achieved within 39 hours. The patient was discharged on postoperative Day 8 and showed no neurological sequelae during the two-week follow-up period.

CONCLUSIONS

This case report demonstrates that inadvertent intrathecal injection of magnesium sulphate during anaesthesia can lead to severe complications. Local pharmaceutical manufacturers are advised to modify ampoule appearance, optimize internal risk-based segregation of high-risk medications, and enforce double-check protocols to reduce the recurrence of similar incidents.