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Implicit faith in technology can mislead: A case of epidural infusion pump malfunction.
Abstract Number: SA-69
Abstract Type: Case Report/Case Series
Modern medicine relies on technologically advanced equipment. We tend to believe that our equipment is highly reliable. Subtle malfunction can go unnoticed and negatively impact patient care. Malfunctions occurring without an error message worsen the situation. Troubleshooting new equipment is more challenging if we do not understand them fully.
We describe an epidural pump (CADD-Solis Model #2110 CE) malfunction that led us to question our epidural placement.
A primigravida admitted to our birthing suite received a routine labor epidural with a standard analgesic solution of 0.2% ropivacaine and 2mcgs of fentanyl per ml with good pain relief and a demonstrable sensory block at T10. Anesthesiology was notified an hour later of breakthrough pain. Patient was dosed with 10 cc of 0.2% ropivacaine over a few minutes with significant pain relief. In an hour, patient was in pain again. At this time, a lack of sensory level to cold was noted. Patient opted to have the epidural replaced and obtained reasonable pain relief with a standard bolus and delivered within an hour.
Our second patient was admitted to the same labor room as the previous case, for a scheduled induction of labor that day. She received a combined spinal epidural due to her morbid obesity and to additionally confirm epidural placement. Patient received 2.5 mg of bupivacaine intrathecally and epidural catheter was threaded without any difficulty. When subarachnoid block had receded, epidural catheter was bloused with 10 cc of 0.2% ropivacaine with 2mcg/of fentanyl per ml in divided doses after a negative test dose to achieve a T-10 sensory block. A standard epidural infusion as was used with the previous case was begun. Four hours later, the patient was in pain and had no detectable sensory level to cold. A bolus of 10 cc of 1% lidocaine was used to rapidly assess the functionality of the epidural catheter. Great pain relief and bilateral T-12 sensory level was achieved with the diagnostic bolus and the epidural infusion was continued. In 2 hours, patient was in excruciating pain and remarked that only physician delivered boluses relieved pain. Neither the infusion nor the PCEA boluses provided any relief. Decision was made to replace the epidural catheter which was done and the infusion restarted after a standard bolus, with good pain relief that again dissipated in 2 hours. Further investigation of this recurrent, timed waning of pain relief found that the epidural infusion bag contained the initial volume that we hung at starting the first epidural. This brought to light the reason why our boluses seemed to help. The pump while appearing to be functional, was not delivering the set dosage. We promptly removed the pump and replaced it with another working epidural pump. This replacement led to good pain relief and the patient progressed to a very comfortable delivery.
The manufacturer returned a report of pump mal-delivery; pump required some replacement of parts.