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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References
Ghoneim MM, Block RI. Learning and consciousness during general anesthesia. Anesthesiology 1992; 76: 279–305.
Brighouse D, Norman J. To wake in fright. BMJ 1992; 304: 1327–8.
Kelly JS, Roy RC. Intraoperative awareness with propo-fol-oxygen total intravenous anesthesia for microlaryngeal surgery. Anesthesiology 1992; 77: 207–9.
Liu WHD, Thorp TAS, Graham SG, Aitkenhead AR. Incidence of awareness with recall during general anaesthesia. Anaesthesia 1991; 46: 435–7.
King H, Ashley S, Brathwaite D, Decayette J, Wooten DJ. Adequacy of general anesthesia for cesarean sectiion. Anesth Analg 1993; 77: 84–8.
Bogetz MS, Katz JA. Recall of surgery for major trauma. Anesthesiology 1984; 61: 6–9.
Hug CC. Does opioid “anesthesia” exist? (Editorial) Anesthesiology 1990; 73: 1–4.
Hilgenberg JC. Intraoperative awareness during highdose fentanyl-oxygen anesthesia. Anesthesiology 1981; 54: 341–3.
Jones JG, Konieczko K. Hearing and memory in anaesthetised patients (Editorial). BMJ 1986; 292: 1291–3.
Russell IF. Midazolam-alfentanil: an anaesthetic? An investigation using the isolated forearm technique. Br J Anaesth 1993; 70: 42–6.
Tunstall ME. Detecting wakefulness during general anaesthesia for Caesarean section. BMJ 1977; 1: 1321.
Dwyer RC, Rampil IJ, Eger EI II, Bennett HL. The electroencephalogram does not predict depth of isoflurane anesthesia. Anesthesiology 1994; 81: 403–9.
Heneghan CPH, Thornton C, Navaratnarajah M, Jones JG. Effect of isoflurane on the auditory evoked response in man. Br J Anaesth 1987; 59: 277–82.
Evans JM, Bithell JF, Vlachonikolis IG. Relationship between lower oesophageal contractility, clinical signs and halothane concentration during general anaesthesia and surgery in man. Br J Anaesth 1987; 59: 1346–55.
Doyle DJ, Tong D. atIntraoperative awareness —a continuing clinical problem (Editorial). Educational Synopses of Anesthesiology and Critical Care Medicine 1996; 3: June. http://gasnet.med.yale.edu/esia/.
Miller DR. Intravenous infusion anaesthesia and delivery devices. Can J Anaesth 1994; 41: 639–52.
Currie J, Owen H, Ilsley AH. Rate-controlled analgesia: a laboratory evaluation of a new infusion device. Anaesth Intensive Care 1990; 18: 555–9.
Baxter InfusOR pump. User’s manual. Baxter Healthcare corporation. Deerfield, IL 60015 USA. 1993.
Stokes DN, Peacock JE, Lewis R, Hutton P. The Ohmeda 9000 syringe pump. The first of a new generation of syringe drivers. Anaesthesia 1990; 45: 1062–6.
Cook RI, Potter SS, Woods DD, McDonald JS. Evaluating the human engineering of microprocessorcontrolled operating room devices. J Clin Monit 1991; 7: 217–26.
Blacker RS. On awakening paralyzed during surgery. A syndrome of traumatic neurosis. JAMA 1975; 234: 67–8.
Blacher RS. Awareness during surgery (Editorial). Anesthesiology 1984; 61: 1–2.
Davis R. Anaesthesia, amnesia, dreams and awareness (Editorial). Med J Aust 1987; 146: 4–5.
Aitkenhead AR. Awareness during anaesthesia: what should the patient be told? (Editorial) Anesthesia 1990; 45: 351–2.
Gild WM. Liability issues associated with awareness during anesthesia. ASA Newsletter 1993; 57: 19–22.
Davies JM, Robson R. The view from North America and some comments on “Down Under”. Br J Anaesth 1994; 73: 105–17.
Guerra F. Awareness during anaesthesia (Letter). Can Anaesth Soc J 1980; 27: 178.
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Tong, D., Chung, F. Recall after total intravenous anaesthesia due to an equipment misuse. Can J Anesth 44, 73–77 (1997). https://doi.org/10.1007/BF03014327
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DOI: https://doi.org/10.1007/BF03014327