Severe hypotension and water intoxication developed after an accidental oxytocin overdose in a morbidly obese patient undergoing cesarean section -A case report

• Published in: Korean journal of anesthesiology Vol. 60; no. 4; pp. 290 - 293
• Main Authors: In, Jang Hyeok, Choi, Jin Woo, Jung, Hong Soo, Lee, Jung-Ah, Joo, Jin-Deok, Kim, Dae-Woo, Jeon, Yeon Soo, Park, Ju-Seon
• Format: Journal Article
• Language: English
• Published: Korea (South) The Korean Society of Anesthesiologists 01.04.2011; Korean Society of Anesthesiologists; 대한마취통증의학회
• Subjects: Case Report; oxytocin; water intoxication; 마취과학; Water intoxication; Oxytocin
• ISSN: 2005-6419; 2005-7563; 2005-7563
• DOI: 10.4097/kjae.2011.60.4.290

We present a 32-year-old, extremely obese, pregnant woman who developed severe hypotension and water intoxication after an accidental injection of large bolus of oxytocin during cesarean section under general anesthesia. The patient was initially thought to have an amniotic fluid embolism because of the abrupt hemodynamic changes developed immediately after fetal delivery and lack of recognition of medication error. It is highly recommended that careful attention should be paid not only to the possibility of hemodynamic deterioration and water intoxication if oxytocin is given rapidly in excessive doses, but to the confirmation of the proper use of the drug before it is injected.