Hypertensive Crisis During Norepinephrine Syringe Exchange

Abstract

A 67-year critically ill patient suffered from a hypertensive crisis (200 mm Hg) because of a norepinephrine overdose. The overdose occurred when the clinician exchanged an almost-empty syringe and the syringe pump repeatedly reported an error. We hypothesized that an object between the plunger and the syringe driver may have caused the exertion of too much force on the syringe. Testing this hypothesis in vitro showed significant peak dosing errors (up to +572%) but moderate overdose (0.07 mL, +225%) if a clamp was used on the intravenous infusion line and a large overdose (0.8 mL, +2700%) if no clamp was used. Clamping and awareness are advised. (A&A Case Reports. 2016;8:178-81.) Copyright © 2016 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the International Anesthesia Research Society. This is an openaccess article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. 3 In addition, characteristics of the infusion system may yield dosing deviations after interventions, such as a syringe exchange, 4 flow rate changes, 5,6 and vertical displacement of the pump. 7 In this case report, we describe a critical care patient receiving an accidental overdose of norepinephrine, probably caused by a pump malfunction during a syringe exchange. Consent for PublicationThe patient's family reviewed the case report and gave written permission (informed consent) to the authors to publish the case report. CASE DESCRIPTIONA 67-year-male patient was admitted to the intensive care unit of the University Medical Center Utrecht, the Netherlands, after a bicycle accident and presented with an out-of-hospital cardiac arrest, a high cervical (C1 and C2) injury, and spinal shock. The patient wished to be treated despite a poor prognosis. The patient's medical history included chronic obstructive pulmonary disease, glaucoma, hypertension, and benign prostatic hypertrophy. Regular home medication included perindopril 8 mg per day. To treat his spinal shock, norepinephrine (0.1 mg/mL by protocol) was administered continuously (5−6 mL/h) with a syringe pump Perfusor Space (B. Braun Perfusor; B. Braun, Melsungen, Germany) to achieve a maintenance dose of approximately 8 to 10 μg/min.The norepinephrine was administered together with a saline carrier flow of 10 mL/h. Both were first connected to 2 standard 1-m infusion lines (Cair LGL, Civrieux d'Azergues, France) and, subsequently, joined with an "octopus" infusion set (CODAN Medical, Lensahn, Germany). The vascular access device used was a 7-Fr triple-lumen catheter (Argon Careflow, Plano, TX) that entered the patient at the v. femoralis. The norepinephrine and saline were connected to the distal lumen of the catheter, another saline infusion (5 mL/h) was connected to the medial lumen, and venous pressure measurement was...

Effects of infusion tubing line lengths and syringe sizes on infusion system compliance: an experimental study using a syringe-type infusion pump at low flow rate

“…In the syringe-type infusion pump system, the use of a smaller syringe would be ideal to minimize system compliance and ow irregularity. However, in real-world clinical practice, the use of small-volume syringes presents issues that inevitably accompany frequent syringe exchanges causing discontinuation of drugs with subsequent start-up delays, increasing the workload of the caregivers as well as the risks of contamination or human errors [24][25][26]. For this reason, syringe-type infusion pumps are frequently used with large-sized syringes.…”