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Correspondence |
Jammu, India
To the Editor:
A recent article by Favier et al., highlighted the successful resuscitation of a patient who experienced severe bupivacaine cardiotoxicity.1 Such incidents are not uncommon in anesthesia practice.2 The authors have concomitantly suggested a number of preliminary measures to prevent such mishaps. They recommend the absolute necessity of careful labelling of syringes and the use of specific syringes with large volumes for local anesthetics. However, both measures have inherent drawbacks. Errors with labelling of syringes have been featured by various authors. Labelling marcaine for bupivacaine has been mistaken for morphine and the bupivacaine label may be mistaken for butorphanol or buprenorphine.3 On the other hand, the use of large volume syringes (20–30 mL) may lead to the accidental administration of relatively large volumes of local anesthetics for neuraxial block with catastrophic results.4
Loss of resistance is the commonest method used to identify the epidural space. This is best accomplished using a 10-mL prepackaged plastic or glass syringe.5 The distinct colour of the plunger of the prepackaged syringe, for instance blue in the Portex epidural set with both horizontal and vertical flanges (in contrast to vertical flanges only or a smooth plunger) can avoid confusion between syringes (Figure
). The feel and weight of the loss of resistance syringe with free and consistent movement of the plunger are well discernable to the experienced hand. One may preferably use such dedicated syringes for neuraxial drug administration. Further, once the syringe is filled with the local anesthetic solution, it should preferably be attached to the Luer lock connector on the epidural catheter rather than kept along with the other syringes containing drugs intended for parenteral administration. Alternatively, syringes containing local anesthetics may be kept along with the Luer lock adaptor in a sterile drape, beside the patient.
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References
1 Favier JC, Da Conceiçao M, Fassassi M, Allanic L, Steiner T, Pitti R. Successful resuscitation of serious bupivacaine intoxication in a patient with pre-existing heart failure. Can J Anesth 2003; 50: 62–6.
2 Karaca S, Unlusoy EO. Accidental injection of intravenous bupivacaine (Letter). Eur J Anaesthesiol 2002; 19: 616–7.
3 Radhakrishna S. Syringe labels in anaesthetic induction rooms. Anaesthesia 1999; 54: 963–8.[Medline]
4 Thomas TA, Cooper GM. Maternal deaths from anesthesia. An extract from why mothers die 1997–1999. The confidential enquiries into maternal death in the United Kingdom. Br J Anaesth 2002; 89: 499–508.
5 Armitage EN. Lumbar and thoracic epidural block. In: Wildsmith JAW, Armitage EN, McClure JH (Eds.). Principles and Practice of Regional Anaesthesia, 3rd ed. New York: Churchill Livingstone; 2003: 139–68.
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