Inadvertent Caudal Epidural Injection of Cefazolin

Mchaourab, Ali; Ruiz, Franklin

doi:10.1097/00000542-200101000-00045

Cited by 14 publications

(17 citation statements)

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“…An analysis of 20 inadvertent injections (2), most often in adults, includes ephedrine, mixture of neostigmine and atropine, thiopental, etilefrine, vecuronium, suxamethonium, bicarbonate, midazolam, lactated Ringer's solution, nicardipine and pentazocine. Injections of metaraminol (3), cefazolin (4) and potassium chloride (5,6) are also reported. No neurological complications were found in any patient.…”

Section: Discussionmentioning

confidence: 99%

Inadvertent epidural infusion of paracetamol in a child

Courrèges

2005

Pediatric Anesthesia

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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.

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Section: Discussionmentioning

confidence: 99%

Inadvertent epidural infusion of paracetamol in a child

Courrèges

2005

Pediatric Anesthesia

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“…The recurrent themes in our identified reports include syringe swap [4][5][6][7][8][9]12,13,32 , wrong ampoule for drug dilution 1,17,18,22,23 and performance of loss of resistance 19,20 technique for epidural insertion. Syringe swaps most commonly involve injection of intravenous induction agents, antibiotics and ephedrine from similar sized syringes, which may or may not be labelled.…”

Section: Types Of Errormentioning

confidence: 99%

“…Increase in blood pressure (5, 12) Ephedrine bolus (5, 12*) Tachycardia, severe occipital headache (12) Antibiotic No effect detected (13-15) -Cefazolin (13,14) Back pain 5 hours following the start of infusion 16 Although much less common, human error can also occur in the pharmacy, with a case of an epidural morphine infusion prepared with 5% dextrose rather than normal saline 11 .…”

Section: Sympathomimeticmentioning

confidence: 99%

“…Measures taken include aspiration of the epidural catheter 7,32 , flushing with distilled water 28 or saline 4,5,[7][8][9]14,24,26,31,32 and insertion of a second epidural catheter for lavage of the epidural space 6 . Epidural local anaesthetic has been used for symptomatic treatment 4,6,12,13,28,29 , epidural or intravenous corticosteroids 6,8,12,17,20,22,23,26,32 to reduce the inflammatory response and epidural hyaluronidase 8 to aid the dispersion of the solution and reduce local concentration. None of these attempts to minimize the risk of an adverse outcome are of proven benefit and some can potentially worsen the situation, resulting in upward spread of drug and further symptoms 24 .…”

Section: Management Of Inadvertent Epidural Injectionmentioning

confidence: 99%

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Avoiding Inadvertent Epidural Injection of Drugs Intended for Non-epidural Use

Hew

Cyna

Simmons

2003

Anaesth Intensive Care

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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.

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“…[1][2][3][4][5][6][7] Most of our knowledge of inadvertent drug injection in the epidural space comes from case reports, and some of our knowledge comes from medico-legal reports, lawsuits, and malpractice litigation. We report a case of inadvertent administration of ephedrine during labor.…”

Section: Introductionmentioning

confidence: 99%