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 Table of Contents  
Year : 2022  |  Volume : 12  |  Issue : 2  |  Page : 158-160

Inadvertent intravenous injection of carboprost in a COVID-19-positive patient: A case report

1 Department of Anaesthesiology and Critical Care, Government Institute of Medical Sciences, Greater Noida, Uttar Pradesh, India
2 Department of Pharmacology, Government Institute of Medical Sciences, Greater Noida, Uttar Pradesh, India

Date of Submission04-Sep-2021
Date of Acceptance02-Mar-2022
Date of Web Publication02-Sep-2022

Correspondence Address:
Dr. Nazia Nazir
Government Institute of Medical Sciences, Greater Noida, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JOACC.JOACC_82_21

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We present a case report of an inadvertent administration of intravenous carboprost in a COVID-19-positive parturient who was taken up for an emergency caesarean section for meconi um-stained liquor. Unintentionally, the patient was administered intravenous carboprost instead of ondansetron. The patient developed breathlessness, uneasiness and hypertension. Despite the mishap, the patient fully recovered and was discharged after 15 days. Although the medical error in the present case was non-harmful, the treating doctor discussed the case with the patient. Conclusion: A case with inadvertent intravenous administration of carboprost in a COVID-19-positive parturient is reported with a good outcome.

Keywords: Carboprost, COVID-19, hypertension, intramuscular, intravenous, medication error

How to cite this article:
Nazir N, Chopra D. Inadvertent intravenous injection of carboprost in a COVID-19-positive patient: A case report. J Obstet Anaesth Crit Care 2022;12:158-60

How to cite this URL:
Nazir N, Chopra D. Inadvertent intravenous injection of carboprost in a COVID-19-positive patient: A case report. J Obstet Anaesth Crit Care [serial online] 2022 [cited 2023 Feb 5];12:158-60. Available from: https://www.joacc.com/text.asp?2022/12/2/158/355355

  Introduction Top

Medication errors contribute to being a major source of iatrogenic harm to patients and preventable adverse events.[1] The errors that occur in the operating room are especially problematic, as the anaesthetist is the only healthcare professional involved in the entire process of prescribing, formulating, dispensing and administering the medication.

The potential for such errors has increased, especially in the present stressful times of the coronavirus disease 2019 (COVID-19) pandemic. The current pandemic has presented challenges to healthcare professionals in terms of adapting to a new way of working, clinical redeployment and other widespread concerns causing stress and anxiety. Reporting medication errors is vital for safety improvement and most importantly to foster honesty in the patient-doctor relationship. Notwithstanding this, disclosure of errors and its discussion with the patients continues to be rare.

Herein, we report a case of a patient who was accidentally administered intravenous carboprost intraoperatively.

  Case Report Top

A 30-year-old primigravida, 38 weeks of gestation with premature rupture of membranes with thick meconium-stained liquor, was taken up for emergency lower segment caesarean section. As per the standard hospital policy, the patient was tested for real-time polymerase chain reaction (RT-PCR), which turned out to be positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Pre-anaesthesia check-up was unremarkable.

She was shifted to the designated COVID-19 operation theatre. One senior anaesthesiologist (with >5 years of experience) and one trainee anaesthesiologist (in the second year of training) were involved in this caesarean section. After starting intravenous fluids and connecting monitors (which showed acceptable haemodynamics), spinal anaesthesia was given in a sitting position, using 0.5% hyperbaric bupivacaine (8 mg) and fentanyl (25 mcg) to achieve a level of T6 dermatome. After delivery of the baby, oxytocin 5 IU intravenous (IV) bolus followed by infusion at 5 IU h−1 was administered. Despite attempts to achieve uterine contraction and oxytocin infusion, the uterine contractions remained inadequate. Hence, it was decided to give intramuscular carboprost 250 mcg (carboprost tromethamine, 250 mcg, Neon Laboratories Limited). At the same time, the patient complained of nausea for which parenteral ondansetron was advised. Labelled syringes containing ondansetron and carboprost were kept on an injection trolley. Inadvertently injection carboprost was administered intravenously instead of injection ondansetron. The mishap was immediately recognised and injection was stopped (0.5 mL of the drug had already been pushed in).

After a few minutes, the patient complained of shortness of breath, uneasiness and headache. Her heart rate increased from 93 beats/min to 140/min, blood pressure increased from 124/87 mmHg to 204/111 mmHg and respiratory rate from 20 breaths/min to 24/min. She maintained her oxygen saturation at 98% on room air heart. A 5-lead ECG showed ST-segment depression. Intraoperative arterial blood gas revealed pH 7.37, pO2 364.7 mmHg, pCO2 31.5 mmHg and HCo3- 20.4. The patient was managed symptomatically with injection of hydrocortisone 100 mg IV, injection of chlorpheniramine 25 mg IV and two puffs of salbutamol with a metered-dose inhaler with a spacer. Given the COVID-19-positive status, nebulisation could not be done (due to the risk of aerosolisation[2]). The patient maintained saturation throughout but was put prophylactically on oxygen supplementation with a non-rebreathing mask with O2 at 10 L/min in view of complaint of shortness of breath by the patient. The symptoms resolved gradually. Despite this mishap, surgery was uneventful and the patient was comfortably shifted to the COVID-19 intensive care unit for postoperative monitoring and then to the isolation ward. Post-operative investigations were within the normal range. The patient was discharged after 15 days after two negative reports for SARS-CoV-2 by RT-PCR.

  Discussion Top

Carboprost, a prostaglandin F2 alpha, is a Food and Drug Administration (FDA)-approved second-line oxytocic after oxytocin and ergometrine.[3] The preferred routes of administration for carboprost are intramuscular or intramyometrial. Intravascular administration of carboprost is not recommended as it can cause significant bronchospasm, nausea, vomiting, hypertension, flushing, hyperpyrexia and myalgia.[3]

In the present case, the patient developed shortness of breath, hypertension with significant ST wave changes due to inadvertent intravenous carboprost administration.[4] The patient was managed symptomatically with salbutamol puffs, injection of hydrocortisone and injection of chlorpheniramine, which are known to produce a reproducible increase in forced expiratory flows.[5],[6] Patient made an uneventful post-operative recovery.

The presented scenario illustrates a medication error where the medicine was administered by a route that is not advisable. The incorrect route of drug administration was a chance occurrence, given the many adverse performance shaping factors that impact workers during the pandemic times. The error did not cause any significant adverse events except increased heart rate, increased blood pressure and ST-segment depression in electrocardiogram (ECG). At the time of discharge, the physician discussed the case with the patient and relatives. Understanding the root cause of such errors can help avoid similar events in the future. As COVID-19 is proving to be a long, uphill battle, with barely an end visible on the horizon. The healthcare workers are exhausted, overwhelmed, with unimaginable anxiety and stress caused by the burden of this pandemic. Needless to say, no one wants to contribute to patient suffering and potential harm. Most patients nowadays want that they should be informed regarding any medical error so that they can be part of decision-making even if the error has not resulted in serious harm.[7] If the physician fails to unveil such an error, the foundation of the fiduciary relationship is destabilised.[8] In addition, evidence from studies shows that disclosing such errors may provide the information necessary to prevent future harmful mistakes.[1],[6],[8]

The root-cause analysis of the reported event was done to discover the underlying causes and prevent future events. The contributors could be the stressful working environment during a COVID-19 surgery. The use of acronyms and abbreviations for syringe labelling, commonly done in operation theatres, may also have contributed to this type of error.

Four out of 10 women in the maternity wards have been reported to have drug-related problems.[9] A multidisciplinary collaboration between physicians, midwifes and pharmacists could prevent these drug-related errors and thereby promote patient safety for pregnant and lactating women. A study conducted in the United States of America identified that 1.8% of medication errors were due to wrong-route administrations.[10] Continuous education of the professionals involved in the medication handling can minimise the harm caused to hospitalised patients due to medication wrong-route administrations, consequently improving the quality-of-care delivery.

  Conclusion Top

This case report is an effort to stress that the medical errors increase if working in a stressful environment as COVID-19 is an additional stressor to the healthcare workers. In such situations, the healthcare workers may dither to disclose a medical error to the patients due to fear of litigation, concern about whether doing this might harm patients. A non-punitive approach should be adopted to improve the rate of reporting of medication errors. The most pressing requirement at this point in time is to stop the blame game, accept mistakes and create a culture of safety so that one can understand what causes medication errors and implement systems to prevent recurring errors.

Author's contributions

Dr. Nazia Nazir contributed to concept, design, the definition of intellectual content, literature search, data acquisition, manuscript preparation, manuscript editing and manuscript review.

Dr. Deepti Chopra contributed to literature search, data acquisition, manuscript preparation, manuscript editing and manuscript review.

All the authors take responsibility for the integrity of the work as a whole from inception to published article and Dr. Nazia Nazir is designated as 'corresponding author'.

Ethics approval and consent to participate

Written informed consent was obtained from the patient.

Human and animal rights

Proper consent was obtained prior to publishing.

Availability of data and materials

The data supporting the findings of the article is available in the adverse drug reaction form stored in the pharmacovigilance cell of the institute.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Kohn LT, Corrigan JM, Donaldson MS. To Err is Human: Building a Safer Health System. Washington (DC): National Academies Press (US); 2000.  Back to cited text no. 1
Amirav I, Newhouse MT. Transmission of coronavirus by nebulizer: A serious, underappreciated risk. CMAJ 2020;30;192:E346.  Back to cited text no. 2
Garg S, Kumar S, Mahajan S. Is intramyometrial carboprost troublesome? J Obstet Anaesth Crit Care 2020;10:150-1.  Back to cited text no. 3
  [Full text]  
Granström L, Ekman G, Ulmsten U. Intravenous infusion of 15 methyl-prostaglandin F2 alpha (Prostinfenem) in women with heavy post-partum hemorrhage. Acta Obstet Gynecol Scand 1989;68:365-7.  Back to cited text no. 4
Popa VT. Bronchodilating activity of chlorpheniramine. J Allergy Clin. Immunol 1977;59:54-63.  Back to cited text no. 5
Chugh J, Yadav YR, Kulkarni HS, Maheshwari S. The effect of aerosolized chlorpheniramine maleate on exercise induced bronchospasm and gas exchange in asthmatics. J Assoc Physicians India 2020;68:21-5.  Back to cited text no. 6
Gallagher TH, Waterman AD, Ebers AG, Fraser VJ, Levison W. Patients' and physicians' attitudes regarding disclosure of medical errors. JAMA 2003;289:1001-7.  Back to cited text no. 7
Wolf ZR, Hughes RG. Error reporting and disclosure. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008. Chapter 35. Available from: https://www.ncbi.nlm.nih.gov/books/NBK2652/.  Back to cited text no. 8
Smedberg J, Bråthen M, Waka MS, Jacobsen AF, Gjerdalen G, Nordeng H. Medication use and drug-related problems among women at maternity wards-a cross-sectional study from two Norwegian hospitals. Eur J Clin Pharmacol 2016;72:849-57.  Back to cited text no. 9
Santell JP, Hicks RW, McMeekin J, Cousins DD. Medication errors: Experience of the United States Pharmacopeia (USP) medmarx reporting system. J Clin Pharmacol 2003;43:760-7.  Back to cited text no. 10


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