Atracurium instead of MMR vaccine

Discussion in 'Anesthesiology' started by bonesmd, 09.20.14.

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  1. bonesmd

    bonesmd Junior Member 10+ Year Member

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  3. FFP

    FFP Offline Gold Donor 7+ Year Member

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    Not surprised. There are many dangerous medications that are packaged almost identically to benign counterparts, even in our anesthesia carts. If the provider is not anal, it's very easy to harm patients.
     
  4. Vaporized

    Vaporized

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    This is an interesting description:
    "
    A doctor at a clinic in the town of Jarjanaz said the infants had exhibited signs of severe shock about an hour after they had been given the injections, with many suffocating to death as their bodies swelled."

    I would think they would just go apneic and die, not go into severe shock with swelling. I know NBNMB are known to have higher incidence of anaphylaxis but that seems odd.
     
  5. anes

    anes ASA Member 2+ Year Member

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    Their bodies were probably already rotting by the time they noticed. What they thought was shock and anaphylaxis was really putrefaction.

    Speaking of mixing up drugs.....

    [​IMG]

    [​IMG]

    this has happened at one of the hospitals I've been at.
     
  6. Uegis

    Uegis 1 Down 3 To Go 10+ Year Member

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    Did they give Zofran instead of Vasopressin? :)
     
  7. Sublimazing

    Sublimazing 2+ Year Member

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    Very tragic...doesn't seem like these drugs should be on access to a non-anesthesiologist....argh
     
  8. Vaporized

    Vaporized

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    Our vaso has orange top. For me I find our glyco continually changes color and volume. Zofran too. Sometimes it is green top like our reglan.
     
  9. kazuma

    kazuma ASA Member 5+ Year Member

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    We had a famotidine- phenylephrine 10mg mixup in preop for an elective C-section case. I cant imagine how terrible the person felt, luckily mom and baby were fine. Those little vials can be notorious/deadly, I always make sure to check them carefully.
     
  10. pgg

    pgg Laugh at me, will they? SDN Moderator 10+ Year Member

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  11. Jay K

    Jay K nullum gratuitum prandium 5+ Year Member

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    I encountered this problem once late night in the Pyxis during an emergent case; Problem was I needed vasopressin, and pharmacy tech had fully stocked the slot with 2 vials of zofran - f-ck me.
     
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  12. pgg

    pgg Laugh at me, will they? SDN Moderator 10+ Year Member

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    Crack a crash cart. Let the restock/inventory/reseal be the pharmacy tech's punishment.
     
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  13. FFP

    FFP Offline Gold Donor 7+ Year Member

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    Atracurium produces histamine release. In an overdose, maybe that was the reason for swelling.
     
  14. fakin' the funk

    fakin' the funk ASA Member 10+ Year Member

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    Dude...to add to the stupidity of a vasopressin/zofran or phenylephrine/famotidine mixup, each of those is 1ml vs 2ml. What is person thinking when they draw up their intended drug and there's only 1ml in there?!?!
     
  15. JobsFan

    JobsFan 10+ Year Member

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    maybe how freakin tired they are, and how they always thought drug x came in concentration y ... oh well
     
  16. kazuma

    kazuma ASA Member 5+ Year Member

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    In the Phenyl-Famotidine debacle, reportedly the pharmacy tech had swapped drugs in the pyxis slots. I always read the label and concentration at least twice when I pick it out and draw it up and then again while I'm pushing it.
     
  17. sevoflurane

    sevoflurane Ride 10+ Year Member

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    We have pharmacy put a special label with different colors to one of the vials that look similar... usually the pressors. This fixes the problem.
     
  18. pgg

    pgg Laugh at me, will they? SDN Moderator 10+ Year Member

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    JC made a big deal about this during our last site visit. IIRC one of our indirect findings was that they found some look-alike vials without pharmacy stickers on them.
     
  19. SaltyDog

    SaltyDog Keeping the Forces of Entropy at Bay 7+ Year Member

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    The most famous one from my residency program was someone giving 4mg of Levophed IV push in pre-op thinking they had drawn up 4mg of Decadron.
     
  20. FFP

    FFP Offline Gold Donor 7+ Year Member

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    Did the patient survive?
     
  21. Hawaiian Bruin

    Hawaiian Bruin Breaking Good 10+ Year Member

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    A couple years before I got there, my shop had a c-section where the careless resident reconstituted a vial of vecuronium instead of the Ancef.

    Turns out being awake and paralyzed was not part of the poor lady's birth plan.
     
  22. Hawaiian Bruin

    Hawaiian Bruin Breaking Good 10+ Year Member

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    My own personal favorite was the 500 units IV insulin given by a student nurse with a braindead preceptor instead of 5mg metoprolol.

    I had fun in the ICU with that one.

    The patient, to his credit, thought the whole thing was hilarious. In his words, "Y'all fcucked up real good, huh?"

    Intern year at the VA was fun.
     
  23. nimbus

    nimbus Member 10+ Year Member

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    We had medical house staff who ordered a dose of vec to "relax" the patient for an LP.
     
  24. SaltyDog

    SaltyDog Keeping the Forces of Entropy at Bay 7+ Year Member

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    Ya guy survived. Luckily it was a young otherwise pretty healthy guy. Did suffer a CVA and some myocardial ischemia in the process though.
     
  25. JSBMD

    JSBMD 2+ Year Member

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    How much volume in a typical MMR vaccine? And, I would expect the erroneously-given atracurium was given IM, not IV. Give your next patient that amount of a nmb and watch what happens.


    Probably nothing.
     
  26. Vaporized

    Vaporized

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    At my program we had someone give non diluted phenylephrine to a patient. I guess the attending kept slamming in propofol by the vial while they were getting other meds ready.

    Came across the vial to the right when looking in the vaso spot in my pyxis. can't upload photo but it is heparin 5000unit per ML with orange top.
     

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