RESUMEN

We present a case of a patient undergoing aortic valve replacement being inadvertently administered 5000 U of bovine thrombin instead of heparin for anticoagulation for cardiopulmonary bypass. The labeling error was made within the operating room pharmacy. The key to survival of this patient was a rapid diagnosis, administration of antithrombin and heparin, and removal of cardiac and great vessel thrombi. It is recommended that point of care anesthesia providers `prepare heparin for cardiopulmonary bypass anticoagulation, as thrombin is not used in anesthetic practice and is not contained within anesthesia cabinet medication drawers.

Asunto(s)

Hemostáticos/efectos adversos , Errores de Medicación , Premedicación , Trombina/efectos adversos , Anciano , Puente Cardiopulmonar , Femenino , Hemostáticos/administración & dosificación , Humanos , Trombina/administración & dosificación