Inadvertent epidural ampicillin administration during labor: case report

Alves, Petra; Antunes, Virgínia; Rodrigues, Adriana; Hipólito, Carla; Horta, Graça

doi:10.1016/j.bjane.2020.02.008

Cited by 1 publication

(5 citation statements)

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“…Currently, there are some case report descriptions of erroneous epidural administration of acetaminophen without complications or development of neurotoxicity symptoms [1,3,6,9]. The majority of those report back on syringe or ampule swaps by healthcare professionals [1][2][3][4][5][6]. However, in this case, the acetaminophen's low-pressure intravenous system was passively connected to the epidural catheter.…”

Section: Discussionmentioning

confidence: 99%

“…Inadvertent administration of any medication via the wrong administration route has the potential for serious morbidity and mortality [1][2][3][4][5][6]. Given the potential complications associated with such errors, and the absence of procedural guidelines or specific treatment in the event they happen [2][3][4][5][6], prevention should be the main strategy [1,3,4,6,7]. Regrettably, because of the ethical implications in such situations, most of our knowledge comes from case reports [2,4,6,7].…”

Section: Introductionmentioning

confidence: 99%

“…Given the potential complications associated with such errors, and the absence of procedural guidelines or specific treatment in the event they happen [2][3][4][5][6], prevention should be the main strategy [1,3,4,6,7]. Regrettably, because of the ethical implications in such situations, most of our knowledge comes from case reports [2,4,6,7]. As such, communicating these errors and any clinical repercussions associated with them is of extreme importance for professionals who are faced with similar situations in their medical practice [2].…”

Section: Introductionmentioning

confidence: 99%

“…The frequency of inadvertent injection of drugs in the epidural space is likely underestimated [1,2,5,6] and underreported, with neurological complications such as paraplegia, urinary incontinence, or sensory alterations [2,[4][5][6] being our main concern. This paper reports on the accidental misconnection of intravenous acetaminophen to an epidural line and of the patient-controlled epidural analgesia (PCEA) pump to an intravenous access.…”

Section: Introductionmentioning

confidence: 99%

“…Regrettably, because of the ethical implications in such situations, most of our knowledge comes from case reports [ 2 , 4 , 6 , 7 ]. As such, communicating these errors and any clinical repercussions associated with them is of extreme importance for professionals who are faced with similar situations in their medical practice [ 2 ].…”

Section: Introductionmentioning

confidence: 99%

See 4 more Smart Citations

Inadvertent Epidural and Intravenous Line Swap: A Case Report

Dias¹,

Ferreira²,

Torres³

et al. 2023

Cureus

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Administration of medication via the wrong administration route has the potential for serious morbidity and mortality. Regrettably, because of the ethical implications in such situations, most of our knowledge comes from case reports. This paper reports on the accidental misconnection of intravenous acetaminophen to an epidural line and of the patient-controlled epidural analgesia (PCEA) pump to intravenous access, as a result of patient error.A male patient aged 60-65 years, 80 kg, American Society of Anesthesiologists (ASA) physical status III presented for unilateral total knee arthroplasty under a combined spinal-epidural anaesthesia technique. For postoperative analgesia, a multimodal analgesia regimen including acetaminophen, in combination with a PCEA pump, was selected.During the night, the patient disconnected and reconnected the drug administration lines, resulting in an epidural/intravenous misconnection. After six unsupervised hours, a total of 114 mg of ropivacaine was administered intravenously and the acetaminophen vial, at this time connected to the epidural catheter, was found empty. A full physical examination by the on-call anaesthesiologist showed no abnormal findings and the nursing staff and patient were instructed on signs to look out for and how to monitor for complications. This case highlights the risks associated with intravenous/epidural line misconnection, as well as the impactful variable the patient represents when admitted to a lower vigilance infirmary. This makes it evident that more safety developments are needed to ensure the utmost quality of care is provided to all patients.

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