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.
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.
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。
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