PDF(Pubmed)
Abstract：
Administration of medication via the wrong administration route has the potential for serious morbidity and mortality. Regrettably, because of the ethical implications in such situations, most of our knowledge comes from case reports. This paper reports on the accidental misconnection of intravenous acetaminophen to an epidural line and of the patient-controlled epidural analgesia (PCEA) pump to intravenous access, as a result of patient error. A male patient aged 60-65 years, 80 kg, American Society of Anesthesiologists (ASA) physical status III presented for unilateral total knee arthroplasty under a combined spinal-epidural anaesthesia technique. For postoperative analgesia, a multimodal analgesia regimen including acetaminophen, in combination with a PCEA pump, was selected. During the night, the patient disconnected and reconnected the drug administration lines, resulting in an epidural/intravenous misconnection. After six unsupervised hours, a total of 114 mg of ropivacaine was administered intravenously and the acetaminophen vial, at this time connected to the epidural catheter, was found empty. A full physical examination by the on-call anaesthesiologist showed no abnormal findings and the nursing staff and patient were instructed on signs to look out for and how to monitor for complications. This case highlights the risks associated with intravenous/epidural line misconnection, as well as the impactful variable the patient represents when admitted to a lower vigilance infirmary. This makes it evident that more safety developments are needed to ensure the utmost quality of care is provided to all patients.
摘要：
通过错误的给药途径给药有可能导致严重的发病率和死亡率。遗憾的是,由于这种情况下的伦理影响，我们的大部分知识来自病例报告。本文报道了静脉内对乙酰氨基酚与硬膜外管路的意外连接以及患者自控硬膜外镇痛（PCEA）泵与静脉通路的意外连接，由于病人的错误。一名60-65岁的男性患者，80公斤,美国麻醉医师协会（ASA）的身体状况III提出了在脊柱-硬膜外联合麻醉技术下进行单侧全膝关节置换术。对于术后镇痛，包括对乙酰氨基酚在内的多模式镇痛方案，与PCEA泵结合使用，被选中。在夜晚，患者断开并重新连接药物管理线路，导致硬膜外/静脉内连接错误。在无人监督的六个小时后，总共114毫克罗哌卡因静脉注射和对乙酰氨基酚小瓶，此时连接到硬膜外导管，被发现是空的。待命麻醉师进行的全面体格检查未发现异常发现，并指示护理人员和患者注意迹象以及如何监测并发症。此病例突出了静脉/硬膜外管路错误连接的相关风险，以及患者入院时所代表的影响变量。这表明需要更多的安全发展，以确保为所有患者提供最高质量的护理。
