Inadvertent bolus administration of high‐dose remifentanil during anesthesia in a 6‐year‐old girl

Abstract

SIR IR-Bolus administration of remifentanil may be associated with bradycardia, hypotension and chest wall rigidity. Remifentanil-induced bradycardia under 1 MAC sevoflurane anesthesia in children was attributed to a negative chronotropic effect (1); remifentanil may also decrease systemic vascular resistance (2). We would like to describe our experience regarding an inadvertent administration of high-dose remifentanil during remifentanilbased desflurane anesthesia in a child.A 6-year-old girl, 20 kg in weight with pelviureteric obstruction was scheduled for pyeloplasty. She had unilateral renal agenesis with the other kidney ectopic in the pelvic region with normal serum urea and creatinine levels. She had a history of hypertension (treated with nifedipine and enalapril), recurrent urinary tract infections and anemia (hemoglobin: 8.4 mgAEdl )1 ). Her heart rate (HR) was 105 bAEmin )1 and arterial blood pressure (BP) was 100/ 60 mmHg in the surgical ward.Anesthesia was induced with a remifentanil infusion (RI), propofol and atracurium; maintained with desflurane, RI and morphine. Surgery was performed via a lumbar incision. During surgery the patient was mildly hypertensive (up to 132/94 mmHg) and tachycardic (127-146 bAEmin )1 ) despite a total dose of 3 mg morphine, 20 mg atracurium, and 600 ml of isotonic solution administered. RI rate was gradually increased to 1.25 lgAEkg )1 AEmin )1 , while endtidal concentration of desflurane was held between 4% and 6%. Arterial blood sampling revealed; pH: 7.29, pCO 2 : 4.7 kPa (36 mmHg), pO 2 : 30 kPa (229 mmHg), HCO 3 : 17.5 mmolAEl )1 , lactate: 0.5 mmolAEl )1 , Cl: 113 mmolAEl )1 (normal range: 98-106), hemoglobin: 7.8 mgAEdl )1 .At the 85th minute of surgery while the BP was 122/ 72 mmHg and HR 133 bAEmin )1 the surgeon complained about inadequate muscle relaxation. A bolus of 500 lg remifentanil instead of atracurium was administered

The effect of age on the dose of remifentanil for tracheal intubation in infants and children

“…Remifentanilinduced muscular rigidity has been reported in adults, but may be less of a clinical problem in children. Indeed, an accidental bolus of 25 lgAEkg )1 of remifentanil in an anesthetized 20-kg child produced no alteration in airway pressures or endtidal CO 2 (22). In our study, chest rigidity was not detected, by evaluating ease of bag mask ventilation, despite bolus administration of remifentanil.…”

Delayed awakening following inadvertent high-dose remifentanil infusion in a 13 year old patient

“…There are limited data about remifentanil hazards; they are reported mostly in pediatric patients [13,15,16]. In our case, the patient was hemodynamically stable without signs of muscle rigidity.…”

Preventing Medication Errors in Pediatric Anesthesia: A Systematic Scoping Review

“…Therefore, the medication process in pediatric anesthesia was judged as highly error prone 3,14 . In practice, dosing errors, syringe swap, and confusions were common in pediatric anesthesia 27,62 . It was not surprising that dosing errors were the most commonly reported issues.…”

“…3,14 In practice, dosing errors, syringe swap, and confusions were common in pediatric anesthesia. 27,62 It was not surprising that dosing errors were the most commonly reported issues. Avidan et al 63 reported a compromised ability of anesthesiologists to calculate weight-specific amounts of drugs for continuous drug administration for pediatric patients.…”