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Correspondence |
West Midlands, UK
To the Editor:
Mahajan1 mentioned several means to reduce the accidental iv injection of drugs drawn up for administration by the epidural route. However, we believe that these measures would merely scratch the surface of the problem.
We do believe that the feel or pressure of the syringe plunger or the colour of the plunger to be too subtle a characteristic to be relied upon in everyday anesthetic practice. Surely, any examination into medical mishaps will soon reveal the quite remarkable capacity for a human to circumvent almost any safeguards against medical error. Surely one of the take-home messages from Favier et al.’s case report2 is to reiterate once again the age-old adage that if you are not 100% certain about the contents of a syringe you should not administer it to anyone and discard it immediately. This goes far beyond the label on the syringe or its colour, but also concerns either drawing up the syringe yourself or having full confidence in the person who did so.
If we were truly serious about avoiding this problem, then the most effective solution would surely be to use an entirely different connection system for epidural catheters and epidural lines. One such example is the Vygon epidural infusion set (Vygon U.K. Ltd, Gloucestershire, England, UK) which incorporates a filter and easy lock adaptor with two syringes (5 mL and 20 mL) with a female Luer Lock (Figure A, B
). Connecting a different syringe i.e., one with a male end is thus rendered impossible.
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References
1 Mahajan R. Avoiding the accidental iv injection of local anesthetics (Letter). Can J Anesth 2003; 50: 1077–8.
2 Favier JC, Da Conceicao 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.
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