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

• Main Authors: Jang Hyeok In, Jin Woo Choi, Hong Soo Jung, Jung-Ah Lee, Jin-Deok Joo, Dae-Woo Kim, Yeon Soo Jeon, Ju-Seon Park
• Format: Article
• Language: English
• Published: Korean Society of Anesthesiologists 2011-04-01
• Series: Korean Journal of Anesthesiology
• Subjects: oxytocin; water intoxication
• Online Access: http://ekja.org/upload/pdf/kjae-60-290.pdf

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.