Regional Anaesthesia and Human Error - A call for vigilance and Close Supervision of Anaesthesia trainees.

Abstract

A 40 year old 56kg, para 0 + 0 woman, was scheduled for drainage of haematometria, haematocolpos and vaginoplasty on account of acquired gynaetrasia. She was classified as American Society of Anesthesiologists (ASA) 1. The operation was commenced under Combined Spinal Epidural (CSE) technique with full complement of monitoring including electrocardiography.
The epidural catheter was to be activated for continued maintenance of anaesthesia. Five, out of 10mls of 0.5% plain bupivacaine meant for this purpose was inadvertently given intravenously. This potentially fatal error was immediately reported and the patient was managed, transferred to the intensive care unit (ICU) after the surgery and discharged to the ward when she had remained stable for 48hours post the incident.
Conclusion: - This case report shows that human error (medication error) can occur during administration of regional anaesthesia and emphasized the need to be vigilant.

Keywords: Regional Anaesthesia, Human Error, Local Anaesthetic toxicity