Accidental alfaxalone overdose in a mature cat undergoing anaesthesia for magnetic resonance imaging

Abstract

This case report describes the clinical signs and treatment of an alfaxalone 10 times overdose in a 12-year-old cat undergoing anaesthesia for MRI. The cat was discharged from hospital following a prolonged recovery including obtunded mentation and cardiorespiratory depression for several hours following cessation of anaesthesia. The cat received supportive therapy that included supplemental oxygen via a face mask, intravenous crystalloid fluids and active rewarming. The benefits of using alfaxalone for maintenance of anaesthesia, its pharmacokinetics and previously reported lethal doses are discussed. Strategies for reducing the incidence of medication errors are presented. An unintentional overdose of alfaxalone by continuous rate infusion has not been reported previously in a cat. Treatment is supportive and directed towards maintenance of the cardiorespiratory systems. Whenever possible, smart pumps that have been designed to reduce human error should be used to help prevent medication errors associated with continuous rate infusions.

Clinical utility of a targeted smartphone application to aid veterinary students in calculating constant rate infusions and perioperative fluid drip rates

“…Medical dosing errors may occur during the perioperative period resulting in unintentional, but preventable, morbidity and mortality 7–9 15. In human medicine, the estimated incidence of peri-anaesthetic period medication errors is between 0.33 per cent and 0.73 per cent per case 3 16 17.…”

“…18 Veterinary case reports have reported severe cardiopulmonary and neurological depression following preventable medication errors due to accidental overdoses of anaesthetic medications. 7 9 A 'smart' syringe pump could minimise medication dosing errors when administering CRIs, 7 but it may not always be inancially feasible for the general veterinary practitioner. The costs of the TSPA used in this study was US$3.99, others available are free or of similar costs, making them afordable for veterinarians and veterinary students.…”

“…In the USA, 16.67 per cent of all human deaths are due to preventable adverse medical events 1. Preventable medical errors remain a continued concern in human1–3 and veterinary medicine 4–7. In the veterinary field, treatment errors are the second most common source of error (30 per cent), second only to surgical treatment errors (41 per cent) 6 8.…”

“…Dosing errors can have a tremendous impact during the peri-anaesthetic period 7 9. Anaesthetists routinely deal with medication mathematics and inability to perform these calculations can lead to morbidity and/or mortality 7 8.…”

“…1 Preventable medical errors remain a continued concern in human [1][2][3] and veterinary medicine. [4][5][6][7] In the veterinary field, treatment errors are the second most common source of error (30 per cent), second only to surgical treatment errors (41 per cent). 6 8 Specifically, medication dosing errors remains one of the leading causes for medical treatment errors in both human 3 and veterinary medicine.…”