10.3389/fpsyg.2012.00132

Vollständiger Abstract

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<h4>Rationale</h4>Epidural analgesia (EA) medication errors are rare but serious adverse events in anesthesia and pain management. Previous literature has predominantly reported errors involving drug types or routes of administration, whereas those caused by infusion devices are uncommon. This case highlights the potential hazard of dose overdose resulting from an abnormal "occlusion" alarm when using a syringe pump for EA bolus.<h4>Patient concerns</h4>A 36-year-old male with recurrent hyperlipidemic severe acute pancreatitis, third episode, was admitted to the intensive care unit (ICU). On admission, the pain score was 7/10 (visual analog scale, VAS). Thoracic epidural analgesia (T8-T9) was administered, with continuous infusion and intermittent boluses of a local anesthetic mixture for pain relief.<h4>Diagnosis</h4>Extensive sympathetic blockade due to EA local anesthetic overdose, manifested as acute hypotension, tachycardia, and bilateral lower limb numbness after EA bolus administration.<h4>Interventions</h4>Given that the patient's pain score was as high as 8/10 on day 4, a 5 ml EA bolus of the analgesic mixture was prescribed. The nurse used a syringe pump for the bolus. Due to high catheter resistance, the pump repeatedly triggered an "occlusion" alarm. The nurse misinterpreted this as no drug infusion and continued the procedure after repeatedly clearing the alarm, ultimately administering approximately 10 ml. Upon recognition, the EA route was immediately closed, and rapid intravenous infusion of 500 ml of compound sodium chloride solution was administered, along with intravenous norepinephrine at 0.2 μg/kg/min via a syringe pump.<h4>Outcomes</h4>Hemodynamics recovered within 10 min, and sensation in both lower limbs gradually returned to normal within 30 min. The patient was transferred to another department 5 days after the event, with no long-term sequelae.<h4>Lessons</h4>Misinterpretation of a syringe pump's "occlusion" alarm during nurse-led epidural bolus administration can lead to local anesthetic overdose. This case underscores the need for improved training on device characteristics and alarm management.

Abstract: PubMed · Datensatz