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Epidural Catheter intravenous mix up dangers

Posted Oct 05 2009 10:03pm

The Institute for Safe Medication Practices devoted their July 2008 Newsletter to Epidural – IV mix ups.   They emphasized the problem of bupivacaine solutions prepared for epidural infusion being given intravenously with subsequent cardiac arrest.   In one case a nurse intending to hang a bag of saline instead hung a virtually identical bag of bupivacaine.   Though the number of such mix ups is low, many occurred in young women.   The reverse also occurs and a case of vincristine injected into the epidural space with subsequent patient death was noted in the report.   Some of the approaches to reduce the incidence of these mix-ups include: 1) substitution of ropivacaine for bupivacaine when clinically appropriate, 2) specially colored epidural tubing with no injection ports, 3) epidural pumps that are distinct from pumps used for intravenous infusions, 4) clear labeling “epidural use only” on bags and syringes used for epidural injection.   Other suggestions include: 1) strict separation of solutions intended for i.v. use from those intended for epidural use, 2) tracing tubing from origin to destination before attaching medication or fluids, 3) hang bags and attach syringes in such a way that their labels are facing out and easily readable.   A final suggestion is manufacturing epidural syringes, bags and tubing with connectors that are not compatible with intravenous syringes, bags or tubing.   This is not just an anesthesia problem.   As noted above, deaths have occurred when vincristine, meant for i.v. use, was given intrathecally (apparently this results in ascending paralysis and severe pain prior to death).    Also, as noted above, there have been cases of epidural solutions of local anesthetics being given i.v.   There are also reports of many types of drugs being given epidurally in error.   The crowded surface of the operating room anesthesia workspace might easily allow the wrong drug to be selected when syringes of drugs for epidural use are left near syringes of drugs meant for intravenous use. For entire article follow this link: http://www.ismp.org/newsletters/acutecare/articles/20080703.asp

 

David Smith, M.D., Ph.D.

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