We describe a patient with refractory myoclonic status epilepticus induced by accidental intrathecal tranexamic acid injection successfully treated with pentobarbital.

Tranexamic acid (C₈H₁₅NO₂) is an antifibrinolytic agent used to reduce bleeding in surgical procedures. The agent also acts to reduce inhibitory current through glycine and GABA receptors, thus increasing excitability, which can result in seizures. Spinal anesthesia kits may contain this medication along with bupivacaine in similar appearing vials leading to accidental intrathecal injection of tranexamic acid, which can result in status epilepticus. Seizure control is variable despite the use of standard anti-epileptic medications. We describe a patient who developed refractory status epilepticus from intrathecal tranexamic acid injection successfully controlled with pentobarbital.

A 78 yo female presented for elective left hip arthroplasty for which she received an epidural injection. After the surgery, she developed generalized myoclonic seizures. The seizure activity continued after intubation and doses of lorazepam, propofol, phenobarbital, levetiracetam, and fosphenytoin. Therefore, she was monitored on continuous EEG and loaded with pentobarbital. EEG initially showed nearly continuous generalized spike-wave discharges accompanied by clinical myoclonus consistent with electrographic and clinical status. As the patient was titrated to near maximum dose of pentobarbital, the pattern evolved to show more suppression, fewer bursts (1-2 per page) and no further myoclonus. Pentobarbital was slowly tapered off and she was maintained on fosphentyoin. After one week, she improved from a medication-induced coma state to following simple commands. Upon hospital discharge after 11 days, she had mild cognitive impairment but otherwise no focal neurological deficits.