硬膜外导管意外注入新斯的明-阿托品混合液。
Inadvertent Administration of Neostigmine-Atropine Mixture from Epidural Catheter.
作者信息
Yıldırım Demet Yüksel, Gürsoy Feray
机构信息
Department of Anaesthesiology and Reanimation, Adnan Menderes University Faculty of Medicine, Aydın, Turkey.
出版信息
Turk J Anaesthesiol Reanim. 2014 Oct;42(5):273-6. doi: 10.5152/TJAR.2014.92300. Epub 2014 Jul 9.
Abstract
Most of the errors encountered during drug applications of anaesthesia may arise from the selection of the wrong syringe and ampule, confusion of epidural and intravenous line, or incorrect dose administration. In this case report, accidental application of reversal drugs via epidural catheter to a patient who was operated on for ureterovesical stenosis is presented. We aimed to indicate the drug errors in anaesthesia practices and discuss measures to be taken to prevent it.
摘要
麻醉药物应用过程中遇到的大多数错误可能源于选错注射器和安瓿、硬膜外导管与静脉输液管混淆，或给药剂量错误。在本病例报告中，呈现了通过硬膜外导管意外给一名因输尿管膀胱狭窄接受手术的患者使用了逆转药物的情况。我们旨在指出麻醉操作中的用药错误，并讨论预防此类错误应采取的措施。
相似文献
1
Inadvertent Administration of Neostigmine-Atropine Mixture from Epidural Catheter.硬膜外导管意外注入新斯的明-阿托品混合液。
Turk J Anaesthesiol Reanim. 2014 Oct;42(5):273-6. doi: 10.5152/TJAR.2014.92300. Epub 2014 Jul 9.
2
[Analysis of inadvertent epidural injection of drugs].[药物意外硬膜外注射分析]
Masui. 2000 Dec;49(12):1391-4.
3
Inadvertent Epidural and Intravenous Line Swap: A Case Report.意外的硬膜外和静脉输液管交换：一例报告
Cureus. 2023 Mar 26;15(3):e36698. doi: 10.7759/cureus.36698. eCollection 2023 Mar.
4
Recovery of lower oesophageal barrier function: a pilot study comparing a mixture of atropine and neostigmine and sugammadex: A randomised controlled pilot study.下食管屏障功能的恢复：比较阿托品和新斯的明混合物与 sugammadex 的一项随机对照初步研究。
Eur J Anaesthesiol. 2021 Aug 1;38(8):856-864. doi: 10.1097/EJA.0000000000001464.
5
[Accidental epidural administration of vecuronium].[维库溴铵意外硬膜外给药]
Masui. 2007 Dec;56(12):1429-32.
6
[Inadvertent epidural ampicillin administration during labor: case report].[分娩期间意外硬膜外给予氨苄西林：病例报告]
Braz J Anesthesiol. 2020 Jan-Feb;70(1):63-65. doi: 10.1016/j.bjan.2019.12.004. Epub 2020 Feb 19.
7
8
Accidental administration of tranexamic acid into the epidural space: a case report.意外将氨甲环酸注入硬膜外腔：病例报告。
Can J Anaesth. 2022 Sep;69(9):1169-1173. doi: 10.1007/s12630-022-02276-3. Epub 2022 Jun 25.
9
Epidural anaesthesia and postoperative colorectal motility--a possible hazard to a colorectal anastomosis.硬膜外麻醉与术后结肠直肠动力——对结肠直肠吻合术可能存在的一种风险。
Int J Colorectal Dis. 1989 Aug;4(3):144-9. doi: 10.1007/BF01649690.
10
Narrative review of neuraxial potassium chloride administration errors: clinical features, human factors, and prevention measures.椎管内氯化钾给药错误的叙述性综述：临床特征、人为因素和预防措施。
Reg Anesth Pain Med. 2021 Oct;46(10):904-908. doi: 10.1136/rapm-2021-102933. Epub 2021 Aug 11.
引用本文的文献
1
Neuraxial and peripheral misconnection events leading to wrong-route medication errors: a comprehensive literature review.导致错误途径用药错误的神经轴和外周连接错误事件：全面文献回顾。
Reg Anesth Pain Med. 2021 Feb;46(2):176-181. doi: 10.1136/rapm-2020-101836. Epub 2020 Nov 3.
本文引用的文献
1
Pre-emptive analgesic and haemodynamic efficacy of combined spinal-epidural neostigmine delivery.腰麻-硬膜外联合注射新斯的明的超前镇痛及血流动力学效应
J Coll Physicians Surg Pak. 2012 Apr;22(4):201-6.
2
A comparative study of two different doses of epidural neostigmine coadministered with lignocaine for post operative analgesia and sedation.两种不同剂量的硬膜外新斯的明与利多卡因联合用于术后镇痛和镇静的比较研究。
J Anaesthesiol Clin Pharmacol. 2010 Oct;26(4):461-4.
3
Epidural neostigmine: will it replace lipid soluble opioids for postoperative and labor analgesia?硬膜外新斯的明：它会取代脂溶性阿片类药物用于术后和分娩镇痛吗？
Anesth Analg. 2009 Aug;109(2):293-5. doi: 10.1213/ane.0b013e3181a891c2.
4
Drug error in anaesthetic practice: a review of 896 reports from the Australian Incident Monitoring Study database.麻醉实践中的用药错误：对澳大利亚事件监测研究数据库中896份报告的综述。
Anaesthesia. 2005 Mar;60(3):220-7. doi: 10.1111/j.1365-2044.2005.04123.x.
5
Caudal neostigmine in children.儿童尾端新斯的明
Br J Anaesth. 2003 Nov;91(5):761; author reply 762. doi: 10.1093/bja/aeg636.
6
ASSOCIATION of Anaesthetists of Great Britain and Ireland.大不列颠及爱尔兰麻醉师协会
Br J Anaesth. 1954 Mar;26(2):151-2.
7
Dose response study of caudal neostigmine for postoperative analgesia in paediatric patients undergoing genitourinary surgery.尾端注射新斯的明用于小儿泌尿生殖系统手术术后镇痛的剂量反应研究。
Paediatr Anaesth. 2003 Jul;13(6):515-21. doi: 10.1046/j.1460-9592.2003.01066.x.
8
Avoiding inadvertent epidural injection of drugs intended for non-epidural use.避免将用于非硬膜外的药物误注入硬膜外。
Anaesth Intensive Care. 2003 Feb;31(1):44-9. doi: 10.1177/0310057X0303100108.
9
A new, safety-oriented, integrated drug administration and automated anesthesia record system.一种新型的、以安全为导向的、集成的药物给药与自动麻醉记录系统。
Anesth Analg. 2001 Aug;93(2):385-90 , 3rd contents page. doi: 10.1097/00000539-200108000-00030.
10
[Analysis of inadvertent epidural injection of drugs].[药物意外硬膜外注射分析]
Masui. 2000 Dec;49(12):1391-4.
Zotero 插件