PDF(Pubmed)
Abstract：
Intravenous (IV) medication administration error remains a major concern during the perioperative period. This review examines inadvertent IV anaesthesia induction agent administration via high-risk routes. Using Medline and Google Scholar, the author searched published reports of inadvertent administration via neuraxial (intrathecal, epidural), peripheral nerve or plexus or intracerebroventricular (ICV) route. The author applied the Human Factors Analysis and Classification System (HFACS) framework to identify systemic and human factors. Among 14 patients involved, thiopentone was administered via the epidural route in six patients. Four errors involved the routes of ICV (propofol and etomidate one each) or lumbar intrathecal (propofol infusion and etomidate bolus). Intrathecal thiopentone was associated with cauda equina syndrome in one patient. HFACS identified suboptimal handling of external ventricular and lumbar drains and deficiencies in the transition of care. Organisational policy to improve the handling of neuraxial devices, use of technological tools and improvements in identified deficiencies in preconditions before drug preparation and administration may minimise future risks of inadvertent IV induction agent administration.
摘要：
在围手术期，静脉（IV）药物给药错误仍然是主要问题。这篇综述研究了通过高风险途径无意的IV麻醉诱导剂给药。使用Medline和GoogleScholar，作者搜索了已发表的关于通过神经轴(鞘内，硬膜外),周围神经或神经丛或侧脑室（ICV）途径。作者应用人为因素分析和分类系统（HFACS）框架来识别系统和人为因素。在涉及的14名患者中，6例患者通过硬膜外途径给予硫喷酮。四个错误涉及ICV的途径（异丙酚和依托咪酯各一种）或腰椎鞘内注射（异丙酚输注和依托咪酯推注）。鞘内注射硫喷酮与一名患者的马尾神经综合征有关。HFACS发现外部心室和腰部引流管的处理欠佳，以及护理过渡方面的不足。改善神经轴装置处理的组织政策，在药物制备和给药前使用技术工具和改善已发现的前提缺陷,可以最大限度地减少未来因意外静脉给药而导致的风险.
