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Accidental administration of epidural Oxytocin in laboring patient: case report and root cause analysis.
Abstract Number: S 59
Abstract Type: Case Report/Case Series
Epidural analgesia during vaginal delivery is widespread practice in current obstetric anesthesia. Epidural administration of unintended substance is well known and potentially devastating complication. Pubmed search reveals epidural administration of chlorhexidine, oxytocin, insulin, vecuronium, rocuronium, atracurium, succinylcholine, tramadol, acetaminophen , potassium chloride, magnesium sulfate, metaraminol, cefazolin, gentamicin, glucose, fat emulsion and dextran. (1-6)
We present a case of healthy G4P3 parturient, scheduled for standard labor analgesia procedure. After uneventful placement and epidural administration of two test doses of what was believed to be 0.1% Bupivacaine with 2mcg/ml of fentanyl. No immediate motor block was detected after first test dose ruling out intrathecal placement. After 5 minutes second test dose was given to establish analgesia level and confirm epidural placement. This is routine way of ruling out intrathecal and intravascular position of epidural catheter adopted by our service. We draw test doses from premade epidural solution bag before procedure start. Soon after test doses it was noticed that by mistake Oxytocin solution of 30 units in 500 ml of NS was attached to epidural tubing though which test doses were drawn. Patient made aware of the error and epidural infusion was never started with regular neurological checks performed every hour. Patient delivered vaginally and no neurologic deficits were assessed. Follow up did not reveal any neurological deficit after 10 days.
We present root cause analysis of this incident with recommendations to reduce the risk of such event happening again.
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2. Accidental epidural administration of Syntocinon. Ross MJ, Wise A. Int J Obstet Anesth. 2012 Apr;21(2):203-4.
3. Accidental epidural injection of rocuronium.
4. Shin SW, Yoon JU, Baik SW, Lee HJ, Ri HS. J Anesth. 2011 Oct;25(5):753-5.
5. [Paraplegia after inadvertent epidural administration of potassium chloride]. Belyamani L, Elmoqadem A, Elbaite A, Mounir K, Drissi Kamili N. Ann Fr Anesth Reanim. 2008 Jan;27(1):111-3.
6. Inadvertent epidural administration of insulin. Kal JE, Vlassak EE, Bulder ER, Franssen EJ. Anaesthesia. 2007 Jun;62(6):621-3.