Apnea after reversal of neuromuscular blockade. A case of rare mix-up

M error is one of the leading causes of morbidity and mortality in hospitalized patients.1 Considering the potency, types, and frequency of the drugs administered to patients undergoing anesthesia, the potential exists for errors with disastrous consequences.2 Several studies indicate that the incidence of medication error associated with anesthesia practice is common. Analysis of critical incidences by Cooper and colleagues3 showed that drug-related events far exceeded the next most common problem, disconnection of the breathing circuit. The Australian Incident Monitoring Study analyzed adverse events during anesthesia and reported that “The wrong drug” was the most common adverse event.4 Indeed, anesthetic drug errors have been reported for every aspect of anesthetic–related care, most common being the “Syringe swaps” (70.4%) and misidentification of the label (46.8%).5 An analysis of closed malpractice claims showed that medication issues are a leading cause of malpractice litigation against Canadian anesthesiologists, totalling 3.5% of claims against all physicians from 1998 to 2002. The most common cause of malpractice action was a medicationrelated event.6 Berman7 reported that errors due to lookalike or sound-alike medication names are common in the United States. Up to 25% of all medication errors are attributed to name confusion, and 33% to packaging or labeling confusion. Systems and recommendations have been developed that may reduce the occurrence of such errors. In our case, an ASA I, male child of 4 years of age and 15 kg body weight was posted for repair of left inguinal hernia under general anesthesia. His routine complete blood count, and biochemistry including urine analysis were within normal limits. The child was premedicated with 5 ml promethazine hydrochloride oral syrup 1 hour before induction of anesthesia. In the operating room, before initiation of anesthesia, his vitals were recorded, his heart rate was 110/minute with normal sinus rhythm, his blood pressure was 106/70 mm Hg and arterial saturation was 99%. An intra-venous cannulation was performed with 22 G cannula without any difficulty and 5% dextrose with one-quarter normal saline started. Anesthesia was induced with 60 mg thiopentone sodium and relaxed with 20 mg suxamethonium, and tracheal intubation was performed with 4.5 mm uncuffed endotracheal tube. Anesthesia was maintained with 25 μgm fentanyl, 50% oxygen with nitrous oxide, 0.6-0.8% sevoflurane and atracurium besylate 0.5 mg/kg as, and when required. Ayre’s T Piece circuit was used for intermittent positive pressure ventilation. Surgery lasted for 45 minutes, and the whole course of anesthesia was uneventful. At the end of surgery, he gained spontaneous respiration, and was kept on 100% oxygen only. Neuromuscular blockade was reversed with 0.75 mg neostigmine and 0.2 mg atropine. After reversal, the heart rate came down from 102/minute to 55/minute and he gradually developed apnea. Heart rate was corrected with the use of atropine. The cause of this fall in heart rate and apnea could not be detected. This unexpected result of reversal alerted us to consider a medication error. A careful check of the syringes loaded with drugs revealed atracurium besylate mixed with neostigmine methyl sulphate instead of atropine. Two syringes kept sideby-side one loaded with atracurium besylate, 5 mg/ml and marked “Atra” and the other syringe loaded with atropine sulphate, 0.1 mg/ml marked “Atro”. In this case, 0.75 mg of neostigmine was mixed with 10 mg of atracurium besylate instead of 0.2 mg of atropine sulphate. The manner in which labeling of the syringes was carried out, could have happened with anyone involved in the anesthetic care of the patient. In this patient, this “mix-up” did not cause any undesirable side effect except prolong apnea and bradycardia, which were taken care of appropriately. Later, when the effect of the muscle relaxant wore off, an appropriate dose of reversal was used and tracheal extubation carried out. He was observed for one hour in recovery and then shifted to the ward without any problem. Though this medication error did not cause any deleterious effect on the patient’s health, it definitely indicates the need for improved standards for drug labeling. To conclude, the utmost care is essential while giving drugs during anesthesia care. To improve patient safety, each medical and surgical discipline needs to identify the sources of error and develop evidence based preventative strategies. The incidence of medication error during anesthesia is uncertain, but it is astonishingly low given the millions of drugs administered during anesthesia care.

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