The volume of the extension set is 1cc.  They are investigating if this volume 
was enough to cause those symptoms (haven't heard what drug), the patient 
hadn't been in PACU very long so still had drugs in her system I'm certain.  
The RN flushed with a prefilled saline syringe.

Cindy Schrum RN CRNI 
IVTeam Coordinator
Gaston Memorial Hospital
Gastonia, North Carolina
(704) 834-2707

>>> <[EMAIL PROTECTED]> 1/16/2006 10:55 PM >>>
 
 
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


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