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当左为右而右为错：一例双侧周围神经阻滞险些误操作的病例报告

When Left Is Right and Right Is Wrong: A Case Report of Two Near-Miss Wrong-Sided Peripheral Nerve Blocks.

作者信息

DeLeon Alexander M, Samworth Alexander G, Kazanji Bashar F

机构信息

Northwestern Memorial Hospital, 251 East Huron Suite F5-704, Chicago, Illinois 60611, USA.

Fellow in Regional Anesthesiology and Acute Pain Medicine, Northwestern Memorial Hospital, 251 East Huron Suite F5-704, Chicago, Illinois 60611, USA.

出版信息

Case Rep Anesthesiol. 2022 Jun 15;2022:1541827. doi: 10.1155/2022/1541827. eCollection 2022.

DOI:10.1155/2022/1541827
PMID:35757103
原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC9217577/
Abstract

Wrong-sided peripheral nerve blocks occur with a surprisingly high frequency despite being described as a "never event." Timeout procedures are performed and documented, yet timeout omission is rarely cited as a contributing factor for wrong-sided blocks. We present two cases of near-miss wrong-sided peripheral nerve blocks and provide recommendations based on the current literature and the most common contributing factors.

摘要

尽管被描述为“绝不允许发生的事件”，但错误侧周围神经阻滞的发生频率却高得出奇。虽然进行了并记录了术前暂停程序，但术前暂停遗漏很少被认为是错误侧阻滞的一个促成因素。我们报告两例险些发生的错误侧周围神经阻滞病例，并根据当前文献和最常见的促成因素提供建议。

https://cdn.ncbi.nlm.nih.gov/pmc/blobs/335b/9217577/d3b726942b3a/CRIA2022-1541827.003.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/335b/9217577/17b2d81d124f/CRIA2022-1541827.001.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/335b/9217577/498de42aff33/CRIA2022-1541827.002.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/335b/9217577/d3b726942b3a/CRIA2022-1541827.003.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/335b/9217577/17b2d81d124f/CRIA2022-1541827.001.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/335b/9217577/498de42aff33/CRIA2022-1541827.002.jpg
https://cdn.ncbi.nlm.nih.gov/pmc/blobs/335b/9217577/d3b726942b3a/CRIA2022-1541827.003.jpg

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本文引用的文献

1
Preprocedural checklist for regional anesthesia: impact on the incidence of wrong site nerve blockade (an 8-year perspective).区域麻醉术前检查表：对错误部位神经阻滞发生率的影响（八年观察）
Reg Anesth Pain Med. 2019 Jan 13. doi: 10.1136/rapm-2018-000033.
2
Wrong-site nerve blocks: A systematic literature review to guide principles for prevention.错误部位神经阻滞：系统文献回顾以指导预防原则。
J Clin Anesth. 2018 May;46:101-111. doi: 10.1016/j.jclinane.2017.12.008. Epub 2018 Mar 2.
3
Wrong-site regional anesthesia: review and recommendations for prevention?
错误部位区域麻醉：预防的综述与建议？
Curr Opin Anaesthesiol. 2015 Dec;28(6):670-84. doi: 10.1097/ACO.0000000000000258.
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Allergic emergencies seen in surgical suites.手术室中出现的过敏性急症。
Clin Rev Allergy Immunol. 1999 Winter;17(4):459-67. doi: 10.1007/BF02737650.