Prolonged neuromuscular block after an accidental epidural injection of vecuronium

Furuya, Takeshi; Suzuki, Takahiro; Yokotsuka, Shoko; Kashiwai, Akihiro; Yoshida, Fumihiko; Kato, Jitsu; Ogawa, Setsuro

doi:10.1016/j.jclinane.2011.01.015

Cited by 6 publications

(3 citation statements)

References 2 publications

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“…Table 1 summarizes the 13 drugs with at least two published cases. Drug classes included: contrast agents, 13 93 general anesthetics, 47 57 60 64 local anesthetics, 11 34–38 muscle relaxants, 46 50 61 antifibrinolytics, 81 92 nonselective adrenergic agonists, 56 59 and nonsteroidal anti-inflammatory drugs. 44 45 The greatest number of patient deaths were due to the erroneous administration of vincristine (n=15), 19 68 73 75–78 80 82 84 87–89 96 thiocolchicoside (n=4), 41 and bupivacaine (n=4).…”

Section: Resultsmentioning

confidence: 99%

Neuraxial and peripheral misconnection events leading to wrong-route medication errors: a comprehensive literature review

Viscusi

Hugo

Hoerauf

et al. 2020

Reg Anesth Pain Med

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We conducted a search of the literature to identify case reports of neuraxial and peripheral nervous system misconnection events leading to wrong-route medication errors. This narrative review covers a 20-year period (1999–2019; English-language publications and abstracts) and included the published medical literature (PubMed and Embase) and public access documents. Seventy-two documents representing 133 case studies and 42 unique drugs were determined relevant. The most commonly reported event involved administering an epidural medication by an intravenous line (29.2% of events); a similar proportion of events (27.7%) involved administering an intravenous medication by an epidural line. Medication intended for intravenous administration, but delivered intrathecally, accounted for 25.4% of events. In the most serious cases, outcomes were directly related to the toxicity of the drug that was unintentionally administered. Patient deaths were reported due to the erroneous administration of chemotherapies (n=16), muscle relaxants (n=4), local anesthetics (n=4), opioids (n=1), and antifibrinolytics (n=1). Severe outcomes, including paraplegia, paraparesis, spinal cord injury, and seizures were reported with the following medications: vincristine, gadolinium, diatrizoate meglumine, doxorubicin, mercurochrome, paracetamol, and potassium chloride. These case reports confirm that misconnection events leading to wrong-route errors can occur and may cause serious injury. This comprehensive characterization of events was conducted to better inform clinicians and policymakers, and to describe an emergent strategy designed to mitigate patient risk.

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Section: Resultsmentioning

confidence: 99%

Neuraxial and peripheral misconnection events leading to wrong-route medication errors: a comprehensive literature review

Viscusi

Hugo

Hoerauf

et al. 2020

Reg Anesth Pain Med

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show abstract

“…22 The peak blood concentration after injection into the central nervous system would be expected to be delayed compared to intravenous administration, but not to the same extent as the local anesthetics. One case 7 of accidental epidural injection of vecuronium showed a doubling of the recovery time from neuromuscular blockade after epidural administration, indicating a somewhat delayed release of the drug from the central nervous system compared to intravenous administration.…”

Section: Discussionmentioning

confidence: 99%

“…Neuromuscular blockade was reversed in 7 patients with neostigmine and atropine. [2][3][4][5][6][7][8] One patient was given pyridostigmine and glycopyrrolate at the end of surgery for reversal. 9 In each of these 8 cases, an acetylcholinesterase inhibitor plus an anticholinergic drug resulted in improvement and recovery of the patient's clinical condition without lasting sequelae.…”

Section: Literature Reviewmentioning

confidence: 99%

Accidental Epidural Injection of Rocuronium in a Pediatric Patient: A Case Report and Literature Review

Wang

Hoff

2016

The Journal of Pediatric Pharmacology and Therapeutics

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Accidental administration of non-epidural drugs into the epidural or subarachnoid spaces may be associated with unexpected pain, morbidity, adverse effects, increased level of care, prolonged hospital stay, and mortality. We describe a 12-month-old admitted for secondary-stage hypospadias reconstruction. General anesthesia was induced with sevoflurane and a peripheral catheter was placed. Instead of ropivacaine, rocuronium (80 mg; 6.3 mg/kg) was injected into the epidural space by the caudal route. Surgery was uneventful and was completed 160 minutes after rocuronium was given. The patient exhibited paralysis with 1 of 4 twitches to the train-of-four with some posttetanic potentiation at the end of surgery. He was transferred to the pediatric intensive care unit for supportive ventilation and recovery. He did not experience oxygen desaturation or hypoventilation between the time of rocuronium administration and intubation. He was hemodynamically stable, without respiratory insufficiency, and his neurologic exam was normal, without motor or sensorial block. The patient was discharged home on the morning of the first postoperative day. Clinical examination 1 week after surgery revealed no lasting sequelae from the error.

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Fall 41 – Die Nachblutung

Ulrich¹,

Hübler²

2022

Mehr Komplikationen in Der Anästhesie

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Prolonged neuromuscular block after an accidental epidural injection of vecuronium

Cited by 6 publications

References 2 publications

Neuraxial and peripheral misconnection events leading to wrong-route medication errors: a comprehensive literature review

Neuraxial and peripheral misconnection events leading to wrong-route medication errors: a comprehensive literature review

Accidental Epidural Injection of Rocuronium in a Pediatric Patient: A Case Report and Literature Review

Fall 41 – Die Nachblutung

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