H. Lee Moffitt Cancer Center & Research Institute, University of South Florida Morsani College of Medicine, 12902 USF Magnolia Dr, Tampa, FL, 33612, USA.
BMC Anesthesiol. 2021 May 12;21(1):143. doi: 10.1186/s12871-021-01372-z.
Epidural catheters are routinely placed for many surgical procedures and to treat various pain conditions. Known complications arising from epidural catheter equipment malfunction include epidural pump failure, epidural catheter shearing, epidural catheter connector failure, epidural filter connector cracking, and loss-of-resistance syringe malfunction. Practitioners need to be aware of these potentially dangerous complications and take measures to mitigate the chances of causing significant patient harm. We report on the complete breakage of an epidural filter connector during epidural bolus administration of local anesthetic by hand with a syringe.
A B. Braun Perifix® epidural catheter was placed in a 73-year-old male scheduled for radical prostatectomy. During the operation, a continuous infusion of local anesthetic was administered through the epidural catheter in addition to general endotracheal anesthesia. At the conclusion of surgery and after extubation, the patient endorsed incisional pain. The epidural filter connector broke in half as a bolus of local anesthetic was administered by hand with a syringe. The local anesthetic sprayed widely throughout the room as the fragmented epidural filter connector became a projectile object that recoiled and struck the patient.
This incident placed the patient and surrounding healthcare providers at substantial risk for injury and infection from the fractured epidural filter connector becoming a projectile object and from the local anesthetic spray. The most plausible cause of this event was from a large amount of pressure being applied to the filter connector. This may have occurred by excessive force being applied by hand to the syringe, by the presence of a clogged filter, or by the catheter being kinked or blocked proximal to the filter. Being aware of this deleterious complication and potentially modifying existing epidural bolus techniques, such as using smaller syringes with less applied force and checking all epidural components vigilantly prior to and during bolus administration, can help anesthesia providers deliver the safest possible care to patients with epidural catheters.
硬膜外导管通常用于许多外科手术和治疗各种疼痛状况。由于硬膜外导管设备故障而引起的已知并发症包括硬膜外泵故障、硬膜外导管断裂、硬膜外导管连接器故障、硬膜外过滤器连接器开裂以及无阻力注射器故障。从业者需要意识到这些潜在的危险并发症，并采取措施降低对患者造成严重伤害的可能性。我们报告了在通过注射器手动进行硬膜外推注局麻药时，硬膜外过滤器连接器完全断裂的情况。
一名 73 岁男性患者拟行根治性前列腺切除术，在其身上放置了一根 B. Braun Perifix®硬膜外导管。手术过程中，除了全身气管内麻醉外，还通过硬膜外导管持续输注局麻药。手术结束并拔除气管导管后，患者表示切口疼痛。当用注射器手动推注局麻药时，硬膜外过滤器连接器断裂成两截。随着碎片状的硬膜外过滤器连接器成为弹射物，局部麻醉剂广泛喷洒在整个房间内，弹射物反弹并击中患者。
此次事件使患者和周围的医疗保健提供者面临严重受伤和感染的风险，因为断裂的硬膜外过滤器连接器成为了一个弹射物，而且局部麻醉剂也会喷溅。造成这种情况最可能的原因是过滤器连接器受到了大量的压力。这可能是由于注射器用力过大，或者过滤器堵塞，或者导管在靠近过滤器的近端扭结或堵塞所致。了解这种有害的并发症，并可能修改现有的硬膜外推注技术，例如使用较小的注射器施加较小的力，以及在推注前和推注过程中仔细检查所有硬膜外组件，都可以帮助麻醉提供者为使用硬膜外导管的患者提供尽可能安全的护理。
