It doesn't surprise me that the anesthesiologist is adamant. I am sure he
thinks he did flush it out and perhaps her did. There is the flush syringe to
consider. Where did the nurse get it from? You need to consider the filling
volume of the PIV and attached extension set. Was that volume enough to allow a
large enough dose of know paralytic agents to stop the patients breathing?
Very interesting case. Never heard of one like it. But do consider
possibilities other than the MD.
Tony West,
RN, CRNI Healix, Inc. Email: [EMAIL PROTECTED] or [EMAIL PROTECTED] SMS:
[EMAIL PROTECTED] Cell: 214-674-4848
In a message dated 1/16/2006 12:07:48 P.M. Central Standard Time,
[EMAIL PROTECTED] writes:
Our risk
management dept has sent me the following scenario. Any one ever have a
similar occurance?
"I am investigating a case re: a pt. in PACU.
The pt. returned from surgery with a prn adapter in her hand. Anesthesia
had started another IV during the procedure due to this one being positional
when they turned her on her stomach. They didn't pull it. When the pt.
got to PACU, the nurse flushed the adapter to see if it was patent. About
10-15 seconds after that the lady couldn't breath, said her tongue was numb
then said she couldn't move then stopped breathing. She required BMV and
then anesthesia gave some reversal meds and she regained respirations.
The thought per PACU RN was that there had been some muscle relaxant left in
the adapter line. Have you ever heard of this or do you have any
resources that may reference something like this? The
anesthesiologist was adamant that they "always flush" after they give meds and
that the pt got IVF after meds but no way of knowing how much d/t IV being
positional and switched. "
As always, I appreciate any feedback,
comments you may have.
Cindy Schrum RN CRNI IVTeam
Coordinator Gaston Memorial Hospital Gastonia, North Carolina (704)
834-2707
----------------------------------------- This message
and any included attachments are from CaroMont Health Inc. and are intended
only for the addressee(s).The information contained herein may include
trade secrets or privileged or otherwise confidential information.
Unauthorized review, forwarding, printing, copying, distributing, or using
such information is strictly prohibited and may be unlawful. If
you received this message in error, or have reason to believe you
are not authorized to receive it, please promptly delete this
message and notify the sender by e-mail with a copy to
[EMAIL PROTECTED]
|
- Re: Drugs left in prn adapter InfusionTx
-