Safer epidural and spinal connectors*

Abstract

SummaryInadvertent cross-connection of epidural local anaesthetic delivery systems with intravenous lines can cause significant morbidity and even death. Inadvertent intrathecal injection of toxic intravenous drugs has already led to many deaths. If epidural and spinal systems had the standard Luer lock connection reversed the problem would be prevented. The practical implications of this idea are explored. Patient safety would be enhanced if this system were adopted.

Recurrent wrong‐route drug error – a professional shame

“…Although the triggering event had numerous contributory procedural weaknesses, initial investigative reports promoted a technical solution in the form of non-Luercompatible connectors for neuraxial interventions [24]. These proposals have been endorsed by key international figures in the field of patient safety [4] and individual members of the UK anaesthetic community [21,25,26], and have prompted published design solutions in Canada [27] and the UK [28]. …”

A response to ‘The nuclear power industry as an alternative analogy for safety in anaesthesia and a novel approach for the conceptualisation of safety goals’

“…Whilst the nuclear engineers had 3 hours to deal with a potential disaster, anaesthetists must diagnose the problem in 3 minutes. Failure to check the equipment (its patency and correct position) when the patient does not respond to treatment of a 'problem airway' features time and time again in anaesthetic disasters [2,3]. This first principle is already known, and so is the warning sign: the combination of hypoxaemia and bradycardia.…”

“…We agree with Dr Powell that patients should not present for vascular surgery without appropriate pre-operative preparation. However, although it is suggested that all patients presenting for vascular surgery should be considered for statin therapy [1], only half of elective abdominal aortic aneurysm (AAA) surgery patients receive statins [2]. The cardiac outcome of major vascular surgical patients may therefore be adversely affected by inadequate medical therapy.…”

“…What remains difficult is to train anaesthetists to use this principle early enough. An excellent example of such system re-design are ports for intrathecal and venous drug administration that are physically incapable of cross connection [2]. Using conventional ports, and despite years of protocol revision and education on the dangers of vincristine administration, approximately one patient a year in Britain has this drug injected into their spinal canal with devastating consequences [3].…”

Improving patient safety with a dedicated neuraxial connector – the CorrectInject© System

“…The disaster of repeated deaths due to this design fault has led to the recommendation that dedicated route-specific connectors be developed [2,3]. We describe the initial clinical evaluation of such a connector for the neuraxial route.…”