Potassium given instead of bupivicaine for neuraxial ---- wtffffff

Started by coffeebythelake
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coffeebythelake

coffeebythelake

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Last edited:
coffeebythelake said:
www.newschannel5.com

Medication mix-up during several surgeries at Ascension St. Thomas Hospital left at least one person paralyzed

Drug mix-up leads to "event" during joint replacement surgeries at Ascension St. Thomas Midtown Hospital, leaving at least one patient permanently paralyzed
www.newschannel5.com www.newschannel5.com



Pharmacy error it sounds like. Compounded medication.

Absolutely terrible.. heartbreaking for the patients..
And.. imagine being the anesthesiologist
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Sounds like they used an epidural infusion as part of their plan. Wonder how this happened?
 
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Someone hung a bag of K without checking and ran the epidural pump?
Or the bag said bupi but it was actually potassium in there?
 
New fear unlocked.
I already don’t trust the pharmacy with these robot made/compounded syringes. In the last 10 years we had one drug swap that was quite dramatic and one episode of wrong concentration epi from the pharmacy made drugs. They reached the patients, but fortunately there was no harm.
I wonder if they used a high concentration potassium bag instead of saline to dilute bupi for the epidural cassette?
Probably should drug test the pharmacist and/or tech that made it. I’m sure they’ll name the anesthesia provider as well in the suit.
What a tragedy.
This is probably some poor inner city hospital that cuts corners and has one (un)supervised pharmacy tech working all night to make all the drugs for the next day.
 
IlDestriero said:
New fear unlocked.
I already don’t trust the pharmacy with these robot made/compounded syringes. In the last 10 years we had one drug swap that was quite dramatic and one episode of wrong concentration epi from the pharmacy made drugs. They reached the patients, but fortunately there was no harm.
I wonder if they used a high concentration potassium bag instead of saline to dilute bupi for the epidural cassette?
Probably should drug test the pharmacist and/or tech that made it. I’m sure they’ll name the anesthesia provider as well in the suit.
What a tragedy.
This is probably some poor inner city hospital that cuts corners and has one (un)supervised pharmacy tech working all night to make all the drugs for the next day.
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Seems like is a pretty big full service hospital in a reasonably nice area of Nashville? Not some podunk underfunded place
 
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coffeebythelake said:
Seems like is a pretty big full service hospital in a reasonably nice area of Nashville? Not some podunk underfunded place
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Same hospital



Comment is interesting:

“The Red Cross is essentially a for profit company that doesn’t pay taxes. The CEO makes over $900k per year and their profits exceed $300M/year. Pay the donors $100 per donation, cut your profits. Btw, anyone whose gotten blood and looked at their hospital bill is disgusted by the cost.“

Many shortages can be solved with money.
 
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Maybe someone in pharmacy had the bright idea that since we only use 2cc out of a 30 cc vial of bupi, they should just draw it up themselves. Backfired bigtime. Similar disasters have happened when TXA ( placed on the anesthesia cart for arthroplasties) was drawn up for spinal instead of the bupi. Double check and triple check all of your spinals. Interestingly, when I was in residency, someone gave a mg of epi in an OB spinal ( was included in the kit for epi wash) and nothing happened….
 
dannyboy1 said:
Maybe someone in pharmacy had the bright idea that since we only use 2cc out of a 30 cc vial of bupi, they should just draw it up themselves. Backfired bigtime. Similar disasters have happened when TXA ( placed on the anesthesia cart for arthroplasties) was drawn up for spinal instead of the bupi. Double check and triple check all of your spinals. Interestingly, when I was in residency, someone gave a mg of epi in an OB spinal ( was included in the kit for epi wash) and nothing happened….
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Digoxin from glass ampules has been given intrathecally too. Ended badly.
 
Not verified but this tracks
IMG_8304.jpeg
 
Lab Lover said:
Does anyone anywhere know of having pharmacy draw up spinal anesthetic meds?
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I think the only way this story makes sense is if they were doing epidurals (which I haven’t seen being done for these), since pharmacy usually just sends a pre-programmed box (with their fentanyl/local mix) to hook up to the epidural catheter after positioning/initial dose in the OR.
 
coolforschool said:
I think the only way this story makes sense is if they were doing epidurals (which I haven’t seen being done for these), since pharmacy usually just sends a pre-programmed box (with their fentanyl/local mix) to hook up to the epidural catheter after positioning/initial dose in the OR.
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Agreed. Pharmacy mixed meds for epidural anesthetics are not uncommon. However, I am not aware of pharmacy preparing a spinal anesthetic injection. Which is why I asked the question.
 
Lab Lover said:
Agreed. Pharmacy mixed meds for epidural anesthetics are not uncommon. However, I am not aware of pharmacy preparing a spinal anesthetic injection. Which is why I asked the question.
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It wouldn’t surprise me, especially since mepivacaine is the local anesthetic in question according to this one source. I could totally see a situation in which a heavy joint service wanting quick turnaround looks at all that wasted carbocaine, and says, we can make a real dent as stewards of precious resources, let’s help out ortho and anesthesia people to premix this stuff. They prepare prefilled medications for intrathecal chemo, I can see an argument to be made for it.

I just don’t see this being an epidural thing, I’m familiar with this place, I did locum’s there, they’re not doing epidurals for their total joints so again, unlikely it’s an epidural bag we are talking about.
 
Reminds me of the string of intrathecal TXA instead of bupivicaine mixups. There was a very high mortality. The glass vials look similar. Some places don’t stock the TXA glass vials for this reason.
www.apsf.org

Unraveling a Recurrent Wrong Drug-Wrong Route Error—Tranexamic Acid in Place of Bupivacaine: A Multistakeholder Approach to Addressing this Important Patient Safety Issue

Notwithstanding technological advances and the ongoing efforts of patient safety advocates, medication administration errors routinely occur in health care facilities across the country. Each day, anesthesia professionals overcome...
www.apsf.org www.apsf.org
 
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Ezekiel2517 said:
Reminds me of the string of intrathecal TXA instead of bupivicaine mixups. There was a very high mortality. The glass vials look similar. Some places don’t stock the TXA glass vials for this reason.
www.apsf.org

Unraveling a Recurrent Wrong Drug-Wrong Route Error—Tranexamic Acid in Place of Bupivacaine: A Multistakeholder Approach to Addressing this Important Patient Safety Issue

Notwithstanding technological advances and the ongoing efforts of patient safety advocates, medication administration errors routinely occur in health care facilities across the country. Each day, anesthesia professionals overcome...
www.apsf.org www.apsf.org
Click to expand...


Similar

www.pharmacytimes.com

Obstetrical Patient Dies After Inadvertent Administration of Digoxin for Spinal Anesthesia | Pharmacy Times

The ampule of digoxin was accidentally taken from automated dispensing cabinet instead of bupivacaine
www.pharmacytimes.com www.pharmacytimes.com
 
The Anesthesia department or group should sue the hospital. It’s unfortunate but this hospital will probably lose staff due to this incident. I could not imagine how the patients the anesthesia providers who had good faith in the supplies and equipment they use to provide care. Heads will roll.
 
narcusprince said:
9 cases, the anesthesia department bears some responsibility in this. After 2 weird spinals someone should have said something to a board runner.
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Let me give you a plausible explanation from the anesthesia view. There might be nothing to suggest anything untoward was going on. These patients weren't coding intraop. They probably did lose sensation to their lower body from the injection and the surgeries happened uneventfully. The delay in return of motor and sensation could have easily been attributed to residual spinal anesthetic. "Just give it more time".. Mepivicaine isnt chloroprocaine. It takes a few hours to wear off. I dont know how ortho heavy they are at the hospital... but it js a pretty big hospital... so 2 or 3 or 4 ORs running ortho cases under spinal, they wouldn't have known
 
BLADEMDA said:
I verify the drug, concentration and expiration date for every bottle.
When it comes to spinals we must be extra careful with the drugs we inject intrathecally.
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Same here. I’m maniacal about sterility, technique and checking the meds with spinals and epidurals. No room for error as the neighborhood is very unforgiving.
 
BLADEMDA said:
On some days I use 5-7 bottles of mepivacaine for spinal anesthetics. Each patient gets his or her brand new bottle even though I have 27-28 mls remaining in the bottle. I verify the drug, concentration and expiration date for every bottle.
When it comes to spinals we must be extra careful with the drugs we inject intrathecally.
Click to expand...
The CDC has a safe injection practice guideline that emphasizes the importance of this practice, even for IV. Essentially, to them, there is no such thing as a multidose vial, even if it says “multidose” on the label.
 
cchoukal said:
The CDC has a safe injection practice guideline that emphasizes the importance of this practice, even for IV. Essentially, to them, there is no such thing as a multidose vial, even if it says “multidose” on the label.
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I remember the olden days when a used multidose vial of labetolol could sit in an anesthesia tray for a month. If we were the one to pop open a new vial we were supposed to date and initial it.
 
NumTacos said:
It wouldn’t surprise me, especially since mepivacaine is the local anesthetic in question according to this one source. I could totally see a situation in which a heavy joint service wanting quick turnaround looks at all that wasted carbocaine, and says, we can make a real dent as stewards of precious resources, let’s help out ortho and anesthesia people to premix this stuff. They prepare prefilled medications for intrathecal chemo, I can see an argument to be made for it.

I just don’t see this being an epidural thing, I’m familiar with this place, I did locum’s there, they’re not doing epidurals for their total joints so again, unlikely it’s an epidural bag we are talking about.
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Why would anyone use a prefilled medication for a spinal? In my 25 years in anesthesia. I have never used any prefilled medicine for a spinal. Never. I have always broken the glass vial myself or crna or resident. Same with snapping the cap off a sterile vial.

Yes ortho is always rushing us. I get it. 1 min saved from breaking the vial and drawing out the medicines.
 
coffeebythelake said:
Let me give you a plausible explanation from the anesthesia view. There might be nothing to suggest anything untoward was going on. These patients weren't coding intraop. They probably did lose sensation to their lower body from the injection and the surgeries happened uneventfully. The delay in return of motor and sensation could have easily been attributed to residual spinal anesthetic. "Just give it more time".. Mepivicaine isnt chloroprocaine. It takes a few hours to wear off. I dont know how ortho heavy they are at the hospital... but it js a pretty big hospital... so 2 or 3 or 4 ORs running ortho cases under spinal, they wouldn't have known
Click to expand...
Totally agree, this is a very busy joint service, they have an entire floor with 8 ORs dedicated just to total joints; it would not surprise me if these were all first case starts. So the idea that someone was supposed to see something immediately from intrathecal potassium seems far fetched, I have no idea if it’s painful or not, but it may not be.
 
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narcusprince said:
Another plausible scenario could be mepivicaine was mixed with potassium. Therefore the spinals would have set up normally and just not recovered followed by a constellation of symptoms. In that scenario I could see the anesthesia team not recognizing right away.
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Why are they even mixing mepivicaine?

I don’t even use duramorph or fentanyl anymore. And I do a lot of ob as well along with tons of orthopedics.

I don’t care. I’m sure people use it like water to mix those two. I just keep it simple.
 
Ortho center I cover from time to time. The 20 cc vial of 2% mepiviciane costs around $500 in bulk. So maybe $20-25 a vial. I use 44mg. Or 2.2 ml. For knees. To be honest I don’t like spinals at stand a lone ASC and I won’t do them for the last case even if I’m getting an obscene amount of money hourly.

But why are they mixing mepivicaine with anything? Use once. Discard.
 
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aneftp said:
Why would anyone use a prefilled medication for a spinal? In my 25 years in anesthesia. I have never used any prefilled medicine for a spinal. Never. I have always broken the glass vial myself or crna or resident. Same with snapping the cap off a sterile vial.

Yes ortho is always rushing us. I get it. 1 min saved from breaking the vial and drawing out the medicines.
Click to expand...
I remember pre-filled syringes for CSE injections containing 2mg spinal bupivacaine and 25mcg fentanyl at a few places I've worked at. The rationale was that if you had to give a CSE to a laboring patient, you didn't have too much time to mix up your own drugs. This practice occured as recently as 2023 where I last worked.
 
IlDestriero said:
Same here. I’m maniacal about sterility, technique and checking the meds with spinals and epidurals. No room for error as the neighborhood is very unforgiving.
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Unfortunately when compounding exists we have to trust that it is done correctly and safely.

Burned_Out said:
I remember pre-filled syringes for CSE injections containing 2mg spinal bupivacaine and 25mcg fentanyl at a few places I've worked at. The rationale was that if you had to give a CSE to a laboring patient, you didn't have too much time to mix up your own drugs. This practice occured as recently as 2023 where I last worked.
Click to expand...

Yep we had those refilled syringes as well where I worked. Big academic center with a dedicated women's hospital
 
narcusprince said:
9 cases, the anesthesia department bears some responsibility in this. After 2 weird spinals someone should have said something to a board runner.
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It wasn't 9, it was 4 per actual reports now. The number 9 came from some tiktok nursefluencer who has no idea the actual details.

We all use medications handed to us from pharmacy every single day. I can't imagine not being able to trust that.
 
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