Inadvertent caudal epidural injection of cefazolin

Inadvertent Injection of Ciprofloxacin Instead of Ropivacaine Through Epidural Catheter

Purpose: Patient harm is often due to medication errors related to neuraxial and peripheral misconnection. We report a case of inadvertent injection of ciprofloxacin into the epidural space and discuss the strategies that could prevent such an incident. Summary: A 74-year-old woman presented a recurrence of an ovarian cancer. The recent discovery of an intrabdominal recurrence on CT-scan led us to propose a new surgical procedure. A thoracic epidural analgesia was performed prior to general anesthesia. Postoperative pain was controlled with patient-controlled epidural analgesia (PCEA) with ropivacaine-epinephrine. During the first night, abdominal pain appeared. During the second day, a nurse discovered that the bag connected to the pump contained ciprofloxacin and not ropivacaine. After aspiration of 2.5 ml sent to laboratory for analysis, the epidural catheter was removed. The investigation revealed the different causes leading to such an error. Three days after, the patient returned home, without any adverse symptoms. Conclusion: This is the first report of the inadvertent administration of ciprofloxacin into the epidural space via a patient-controlled epidural analgesia technique. As there is no effective treatment for such errors, we discuss the neurological risk of ciprofloxacin and prevention strategy mainly based on organizational and human factors.

Preventing Medication Errors in Pediatric Anesthesia: A Systematic Scoping Review

OBJECTIVE

Preventing medication errors and improving patient safety in pediatric anesthesia are top priorities. This systematic scoping review was conducted to identify and summarize reports on medication errors in pediatric anesthesia. The study also aimed to qualitatively synthesize medication error situations in pediatric anesthesia and recommendations to eliminate/minimize them.

METHODS

The databases: Cochrane, MEDLINE through PubMed, Embase, CINAHL through EBSCO, and PsycINFO were extensively searched from their inception to March 3, 2020. Error situations in pediatric anesthesia and recommendations to minimize/reduce these errors were synthesized qualitatively. Recommendations were graded by level of evidence using the methodology of the Joanna Briggs Institute.

RESULTS

Data were extracted from 39 publications. Dosing errors were the most commonly reported. Scenarios representing medication (n = 33) error situations in pediatric anesthesia and recommendations to eliminate/minimize medication errors (n = 36) were qualitatively synthesized. Of the recommendations, 2 (5.6%) were related to manufacture, 4 (11.1%) were related to policy, 1 (2.8%) was related to presentation to user, 1 (2.8%) was related to process tools, 17 (47.2%) were related to administration, 3 (8.3%) were related to recording/documentation, and 8 (22.2%) recommendations were classified as others. Of those, 29 (80.6%), 3 (8.3%), 3 (8.3%), and 1 (2.8%) were graded as evidence level 1, 2, 3, and 5, respectively.

DISCUSSION

Medication error situations that might occur in pediatric anesthesia and recommendations on how to eliminate/minimize medication errors were also qualitatively synthesized. Adherence to recommendations might reduce the incidence of medication errors in pediatric anesthesia.

[Inadvertent epidural ampicillin administration during labor: case report]

BACKGROUND

Inadvertent epidural drug administration is associated with morbidity and mortality. Several drugs have been administered accidentally through the epidural catheter and most of our knowledge is based on case reports.

CASE REPORT

A 33 year-old woman presented for delivery. Placement of epidural catheter was requested for labor analgesia and priming dose was administered. Five minutes later, ampicillin 1g was given through the catheter inadvertently without hemodynamic or neurological changes. Ropivacaine administration was repeated, always with symptomatic relief until delivery. At hospital discharge, she remained without neurological or hemodynamic alterations.

CONCLUSIONS

The majority of errors are due to syringe and drug exchanges, and inadvertent route administration. Erroneous administration into the epidural space can have immediate and late effects and there is no definitive and effective treatment. There are several preventive measures to reduce the potential complications; some opt for watchful waiting, others opt for administering other drugs as a dilution attempted.

Inadvertent epidural ampicillin administration during labor: case report

Background

Inadvertent epidural drug administration is associated with morbidity and mortality. Several drugs have been administered accidentally through the epidural catheter and most of our knowledge is based on case reports.

Case report

A 33 year-old woman presented for delivery. Placement of epidural catheter was requested for labor analgesia and priming dose was administered. Five minutes later, ampicillin 1 g was given through the catheter inadvertently without hemodynamic or neurological changes. Ropivacaine administration was repeated, always with symptomatic relief until delivery. At hospital discharge, she remained without neurological or hemodynamic alterations.

Conclusions

The majority of errors are due to syringe and drug exchanges and inadvertent route administration. Erroneous administration into the epidural space can have immediate and late effects and there is no definitive and effective treatment. There are several preventive measures to reduce the potential complications; some opt for watchful waiting, others opt for administering other drugs as a dilution attempted.

Unintentional Infusion of Phenylephrine into the Epidural Space

We describe a patient who received an unintentionally prolonged epidural infusion of phenylephrine. The patient experienced no major morbidity. However, this case highlights the continuing problem of wrong-route drug administration and the urgent need to adopt route-specific connections.

Inadvertent epidural infusion of paracetamol in a child

An 11-year-old boy underwent lumbar epidural anesthesia under general anesthesia to provide intra- and postoperative analgesia for a severe burn of his lower limb. A dural tap at the L4-L5 space occurred during the epidural approach. A second attempt through the upper intervertebral space was successful. Postoperatively, the boy was given both continuous epidural analgesia and intravenous (i.v.) infusions. These latter were provided using two similar double track pumps. At the 36th postoperative hour a nurse injected paracetamol using inadvertently the epidural instead of the i.v. pump. The mistake was repeated 6 h later. The boy experienced both headache and vomiting. Symptoms seemed to be a mechanical rather than a toxic complication. They disappeared for 48 h under treatment including saline and caffeine. Neurological examinations stayed normal. No sequelae were noted. The frequency of this type of medication incident is probably underestimated. The literature notes a large list of injected drugs, but paracetamol had never been described.

Inadvertent epidural injection of ephedrine in labor

Drugs mistakenly administered into the epidural space can have serious neurologic sequelae. This case reports the inadvertent administration of ephedrine during labor in a 17-year-old woman. The possible complications for both the mother and fetus are discussed and compared with other published literature reports.

Avoiding inadvertent epidural injection of drugs intended for non-epidural use

Inadvertent administration of non-epidural medications into the epidural space has the potential for serious morbidity and mortality. The aim of this study was to collate reported incidents of this type, describe the potential mechanisms of occurrence and identify possible solutions. We searched medical databases and reviewed reference lists of papers retrieved, covering a period of 35 years, regarding this type of medication incident. The 31 reports of 37 cases found is likely to represent a gross underestimation of the actual number of incidents that occur. "Syringe swap", "ampoule error", and epidural/intravenous line confusion were the main sources of error in 36/37 cases (97%). Given that no effective treatment for such errors has been identified, prevention should be the main defence strategy. Despite all the precautions that are currently undertaken, accidents will inevitably occur. We have identified areas for systemwide change that may prevent these types of incidents from occurring in future.