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Cardiac arrhythmia from epinephrine overdose in epidural test dose

Medication shortages are a clinical reality that force changes in practice patterns leading to unintended consequences. Potential solutions to any drug shortage require a thoughtful, multidisciplinary and often creative approach. Here, we report a case of unintentional epinephrine overdose leading t...

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Autores principales: Borden, Shelly B., Groose, Molly K., Robitaille, Mark J., Schroeder, Kristopher M.
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Wolters Kluwer - Medknow 2019
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6625278/
https://www.ncbi.nlm.nih.gov/pubmed/31333374
http://dx.doi.org/10.4103/sja.SJA_218_19
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author Borden, Shelly B.
Groose, Molly K.
Robitaille, Mark J.
Schroeder, Kristopher M.
author_facet Borden, Shelly B.
Groose, Molly K.
Robitaille, Mark J.
Schroeder, Kristopher M.
author_sort Borden, Shelly B.
collection PubMed
description Medication shortages are a clinical reality that force changes in practice patterns leading to unintended consequences. Potential solutions to any drug shortage require a thoughtful, multidisciplinary and often creative approach. Here, we report a case of unintentional epinephrine overdose leading to an unstable cardiac arrhythmia and our subsequent development of a visual cue system to prevent future errors. A 56-year-old man with a history of rectal adenocarcinoma presented for low anterior resection and creation of diverting loop ileostomy. Epidural placement was requested by the surgical team, and following administration of a second test dose (created by the physician), the patient experienced supraventricular tachycardia with heart rates of 200-210 BPM for approximately 2 minutes. This rhythm then converted to atrial fibrillation with rapid ventricular response with heart rate of 150-170 BPM. The patient was stabilized after cardioversion. Later evaluation of medication administration revealed that the second epidural test dose inadvertently contained 100 mcg epinephrine instead of the intended 10 mcg dose. The test dose had to be created because the original ampule with the kit had been utilized. Since this time, our kits have no test dose, and this shortage is concerning for increased provider error. We suggest a novel visual cue system that may prevent unintentional epinephrine overdoses in the setting of regional anesthesia.
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spelling pubmed-66252782019-07-22 Cardiac arrhythmia from epinephrine overdose in epidural test dose Borden, Shelly B. Groose, Molly K. Robitaille, Mark J. Schroeder, Kristopher M. Saudi J Anaesth Case Report Medication shortages are a clinical reality that force changes in practice patterns leading to unintended consequences. Potential solutions to any drug shortage require a thoughtful, multidisciplinary and often creative approach. Here, we report a case of unintentional epinephrine overdose leading to an unstable cardiac arrhythmia and our subsequent development of a visual cue system to prevent future errors. A 56-year-old man with a history of rectal adenocarcinoma presented for low anterior resection and creation of diverting loop ileostomy. Epidural placement was requested by the surgical team, and following administration of a second test dose (created by the physician), the patient experienced supraventricular tachycardia with heart rates of 200-210 BPM for approximately 2 minutes. This rhythm then converted to atrial fibrillation with rapid ventricular response with heart rate of 150-170 BPM. The patient was stabilized after cardioversion. Later evaluation of medication administration revealed that the second epidural test dose inadvertently contained 100 mcg epinephrine instead of the intended 10 mcg dose. The test dose had to be created because the original ampule with the kit had been utilized. Since this time, our kits have no test dose, and this shortage is concerning for increased provider error. We suggest a novel visual cue system that may prevent unintentional epinephrine overdoses in the setting of regional anesthesia. Wolters Kluwer - Medknow 2019 /pmc/articles/PMC6625278/ /pubmed/31333374 http://dx.doi.org/10.4103/sja.SJA_218_19 Text en Copyright: © 2019 Saudi Journal of Anesthesia http://creativecommons.org/licenses/by-nc-sa/4.0 This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
spellingShingle Case Report
Borden, Shelly B.
Groose, Molly K.
Robitaille, Mark J.
Schroeder, Kristopher M.
Cardiac arrhythmia from epinephrine overdose in epidural test dose
title Cardiac arrhythmia from epinephrine overdose in epidural test dose
title_full Cardiac arrhythmia from epinephrine overdose in epidural test dose
title_fullStr Cardiac arrhythmia from epinephrine overdose in epidural test dose
title_full_unstemmed Cardiac arrhythmia from epinephrine overdose in epidural test dose
title_short Cardiac arrhythmia from epinephrine overdose in epidural test dose
title_sort cardiac arrhythmia from epinephrine overdose in epidural test dose
topic Case Report
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6625278/
https://www.ncbi.nlm.nih.gov/pubmed/31333374
http://dx.doi.org/10.4103/sja.SJA_218_19
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