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Accidental administration of succinylcholine for the treatment of hypotension in a labouring parturient

San Diego, California

To the Editor:

In the Labour and Delivery (L&D) Suite at the University of California, San Diego several emergency medications including succinylcholine and ephedrine have been supplied routinely by the hospital pharmacy in premixed ready-to-use syringes. Recently, secondary to a syringe mislabelling error (succinylcholine labelled as ephedrine), a labouring parturient accidentally received succinylcholine (instead of ephedrine) for the treatment of hypotension.

A 23-year-old, gravida 2, para 1, healthy female at 38 weeks gestation labouring under uneventful continuous lumbar epidural anesthesia required ephedrine for the treatment of hypotension. A 10-mg (2 mL) iv dose of "ephedrine" was administered by the anesthesia resident. Apnea and loss of consciousness quickly followed and a code blue was called. Mask ventilation was performed until spontaneous breathing resumed and consciousness was regained one to two minutes later. There were no untoward sequelae, and the patient delivered a healthy newborn several hours later. Independent laboratory analysis of the content of the syringe labelled as ephedrine confirmed a misla-belling error (the syringe contained 15 mg·mL^–1 of succinylcholine).

This event sparked a discussion amongst our faculty on whether anesthesia providers in the L&D Suite should prepare these drugs themselves (despite the low likelihood of their use) similarly to practice in the main operating room. As a consequence of these discussions, our long-term tradition was abandoned and anesthesiologists now prepare their own medications daily.

Fasting and Gisvold¹ studied the pattern and frequency of drug errors in clinical anesthesia and concluded that drug errors are uncommon, and represent a small part of anesthesia problems but still have the potential for serious morbidity. Syringe swaps most commonly involved muscle relaxants and occurred most often between syringes of equal size, and were not eliminated by colour-coding of labels. Orser et al.² conducted a self-reporting survey of the members of the Canadian Anesthesiologists’ Society (n = 2,266) regarding the frequency of drug errors and concluded that most anesthesiologists (85% of the participants) experienced at least one drug error. The commonest error was a syringe swap involving a muscle relaxant. Most errors were of minor consequence, however, serious morbidity and mortality resulted from clearly preventable events.

We would be interested to hear from colleagues with similar experiences from other institutions.

References

1 Fasting S, Gisvold SE. Adverse drug errors in anesthesia, and the impact of coloured syringe labels. Can J Anesth 2000; 47: 1060–7.[Abstract]

2 Orser BA, Chen RJ, Yee DA. Medication errors in anesthetic practice: a survey of 687 practitioners. Can J Anesth 2001; 48: 139–46.[Abstract/Free Full Text]

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