Recall after total intravenous anaesthesia due to an equipment misuse

Clinical Report

Abstract

Purpose

To present a case of recall after total intravenous anaesthesia (TIVA) with propofol-alfentanil infusions to point out an uncommon misuse of the Bard InfusOR syringe driver.

Clinical features

A healthy patient underwent diagnostic dilatation and curettage and laparoscopy for lysis of peritoneal adhesions. After induction, anaesthesia was maintained with propofol-alfentanil infusions using the Bard InfusOR syringe drivers. Ten minutes into maintenance, the patient was moving. The flashing green light confirmed the delivery of the medication and the alarms were not activated. However, the latch of the movable lever in the propofol syringe driver was found to be improperly positioned at the top of the plunger and only a small amount of propofol had been delivered. Postoperatively, the patient could recall the abdomen being touched during laparoscopy. An explanation was given and the patient was satisfied.

Conclusion

The Bard InfusOR syringe driver is not designed to detect a malposition of the lever on the synnge plunger. The anaesthetist must ensure proper placement of the lever and visual confirmation of medication delivery in order to prevent awareness due to this particular problem.

Résumé

Objectif

Rapporter un incident de rappel consécutif à une anesthésie exclusivement intraveineuse (AEIV) réalisée avec une perfusion de propofol-fentanyl dans le but d’attirer l’attention sur l’emploi incorrect d’un poussesenngue Bard InfusOR.

Éléments cliniques

Une patiente en bon état subissait une dilatation avec curetage pour fin diagnostique et une laparoscopie pour lyse d’adhérences péritonéales. Après l’induction, l’anesthésie était maintenue à l’aide d’un pousse-seringue Bard InfusOR. Dix minutes plus tard, la patiente bougeait. Le clignotant vert lumineux confirmait l’administration de la médication et aucune alarme n’était activée. Cependant, on constatait que le loquet du levier mobile du pousse-seringue était mal placé sur la tête du piston et que seulement une petite quantité de propofol avait été reçue. En postopératoire, la patiente se rappelait qu’on lui avait touché l’abdomen. Après explications, la patiente s’est déclarée satisfaite.

Conclusion

Le pousse-seringue Bard InfusOR n’est pas conçu pour détecter le placement incorrect du levier sur le piston de la senngue. L’anesthésiste doit s’assurer que le levier est en bonne position et que la médication est reçue dans le but de prévenir un rappel causé par ce type de problème.

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Copyright information

© Canadian Anesthesiologists 1997

Authors and Affiliations

  1. 1.Department of Anaesthesia, Western Division, The Toronto HospitalUniversity of TorontoToronto

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