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Article in Indianjournalofanaesthesia·July2016

DOI:10.4103/0019-5049.186014

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DOI:10.4103/0019-5049.186014 CITATIONS 0 1author: RabiulAlam CMH,Dhaka,Bangladesh 33 PUBLICATIONS 13

CMH,Dhaka,Bangladesh

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Letters to Editor

the ear pinna and stiff and hard helical cartilage were noted in our patient can easily be missed. [6] Calcifications in the coronaries, cardiac valves and aortic root, urinary pigment calculi and nephrotoxicity may be significant enough to alter anaesthetic management. [2]

Although surgical implications are minimal, surgeons should involve the anaesthesiologist, physician and cardiologist early in the pre-operative period to establish a well-planned management approach.

Acknowledgement Dr. Firdos Saba and Dr. Asha Prabhakar of SRL Diagnostics, Bengaluru, India, for providing digital histopathology images.

Financial support and sponsorship Nil.

Conflicts of interest There are no conflicts of interest.

Kanchan Bilgi, Satish Jagadeeshan, Prabhakaran Venugopal 1

Kanchan Bilgi, Satish Jagadeeshan, Prabhakaran Venugopal 1 Departments of Anaesthesiology and 1 Orthopaedic

Departments of Anaesthesiology and 1 Orthopaedic Surgery, Hospital for Orthopaedics, Sports Medicine, Arthritis and Accident‑Trauma, Bengaluru, Karnataka, India

Address for correspondence:

Dr. Kanchan Bilgi, Department of Anaesthesiology, Hospital for Orthopaedics, Sports Medicine, Arthritis and Accident-Trauma, 45, Magrath Road, Off Richmond Road, Bengaluru, Karnataka, India. E-mail: kanchanbilgi@gmail.com

REFERENCES

1.

Garrod AE. Classics of biology and medicine: The incidence

of alkaptonuria: A study in chemical individuality. Yale J Biol Med 2002;75:221-31. [Originally Published in The Lancet

1902;1616-20].

2.

Phornphutkul C, Introne WJ, Perry MB, Bernardini I, Murphey MD, Fitzpatrick DL, et al. Natural history of alkaptonuria. N Engl J Med 2002;347:2111-21.

3.

Ranga U, Aiyappan SK, Shanmugam N, Veeraiyan S. Ochronotic spondyloarthropathy. J Clin Diagn Res 2013;7:403-4.

4.

Yildirim AÖ, Altas O, Öken ÖF, Yildirim İ, Uçaner A. Undefined findings of ochronotic polyarthropathy- cervical pseudoankylosis, spinal cord atrophy and anterior mediastinal mass: Case report. Eur J Surg Sci 2014;5:39-42.

5.

Lindner M, Bertelmann T. On the ocular findings in ochronosis:

A

systematic review of literature. BMC Ophthalmol 2014;14:12.

6.

Groseanu L, Marinescu R, Laptoiun D, Botezatu I, Staniceanu

F, Zurac S, et al. A late and difficult diagnosis of ochronosis. J

Med Life 2010;3:437-43.

This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

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How to cite this article: Bilgi K, Jagadeeshan S, Venugopal P. Difficult epidural in a patient with undiagnosed alkaptonuria. Indian J Anaesth 2016;60:523-5.

Spinal needle with prefilled

syringe to prevent medication

error: A proposal

Sir,

We read several case-reports of medication errors concerned with subarachnoid block. The chance of making an inadvertent error is always a possibility. Any error may cause irreversible physical damages and significantly enhance the financial cost to human tragedy. It is an alarming finding that more people die from medical errors than motor vehicle accidents,

breast cancer, or HIV; but unfortunately, these statistics never appropriately figure in public media or deliberations. [1] Another study showed that about two out of every hundred inpatients experience a preventable adverse drug event, resulting in an average increase of hospital costs by $4700 per admission. [2] Therefore, medical errors should be prioritised as an urgent, critical and widespread public health problem.

A few horrific cases of erroneous drug administration do make the news headlines, either because they involve a celebrity or due to their terrible nature. Unfortunately, they constitute only the tip of the iceberg. On the other side, there are many stories of successes in rescuing the unfortunate victims

Indian Journal of Anaesthesia | Vol. 60 | Issue 7 | Jul 2016

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525

Letters to Editor

Letters to Editor Figure 1: Ampules of tranexamic acid and bupivacaine heavy without any residual effect,

Figure 1: Ampules of tranexamic acid and bupivacaine heavy

without any residual effect, but fatal outcomes are not few. [3] Recently, in our centre, a 28-year-old parturient (2 nd gravida) with pregnancy-induced hypertension encountered a serious catastrophe by accidental intrathecal injection of tranexamic acid for emergency caesarean section. Management was tried as per evidence-based protocols, but the patient developed quadriparesis.

Another incident experienced 1 year back concerned

a 27-year-old male who was received in the

emergency and put on a mechanical ventilator. The patient had developed severe convulsions followed by unconsciousness immediately after receiving subarachnoid block for lower limb surgery in a peripheral hospital. The patient eventually developed brainstem death and subsequently the outcome was fatal. The exact cause of the first incident was unearthed by proper inquiry, but the definite reasons of the second one remained ambiguous.

Human errors, look-alike drug labels, haste and fatigue

are indicated as the most common causes very correctly. [4]

However, sometimes it may happen even when multiple drug labels do not exactly look alike what revealed in one of our incidents [Figure 1]. Many useful and valuable recommendations are formularised to prevent the medication errors. [5] However, more definitive systems need to be engineered to reduce the likelihood of medication misidentification through approaches such as revision of standards for labelling of drug ampoules and vials and the development of advanced electronic/ digital mechanisms that allow ‘double-checking’ or drug verification in the operating room.

or drug verification in the operating room. Figure 2: Spinal needle with prefilled syringe In this

Figure 2: Spinal needle with prefilled syringe

In this context, particularly to prevent the medication

errors during the intrathecal administration of local anaesthetics, we propose to change the presentation and packaging of the appliances and agents used for this purpose. One spinal needle with a syringe prefilled

with the local anaesthetic agents may be marketed in a

single blister pack [Figure 2], which will be peeled open and presented before the anaesthesiologist conducting the procedure. This presentation might not only reduce the medication mis-identification, it could also have

a significant role in infection control. Bupivacaine

hydrochloride is found to be stable in polypropylene syringes [6] and can be utilised; the product will not become much expensive. [7] Experiments on prolongation of stability of hyperbaric local anaesthetics in polypropylene syringes and specific recommendations for preservation protocols may be required.

Financial support and sponsorship Nil.

Conflicts of interest There are no conflicts of interest.

Conflicts of interest There are no conflicts of interest. Md Rabiul Alam Department of Anaesthesia, Combined

Md Rabiul Alam

Department of Anaesthesia, Combined Military Hospital, Dhaka, Bangladesh

Address for correspondence:

Dr. Md Rabiul Alam, Department of Anaesthesia, Combined Military Hospital, Dhaka, Bangladesh. E-mail: rabiuldr@gmail.com

REFERENCES

1. Dhawana I, Tewarib A, Sehgalc S, Sinhad AC. Medication errors in anesthesia: Unacceptable or unavoidable? Braz J Anesthesiol 2016. [Ahead of Print] Available from:

http://dx.doi.org/10.1016/j.bjane. 2015.09.006.

526526

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Letters to Editor

Drug Events Prevention Study Group. JAMA 1997;277:307-11.

3. Butala BP, Shah VR, Bhosale GP, Shah RB. Medication error:

Subarachnoid injection of tranexamic acid. Indian J Anaesth

2012;56:168-70.

4. Arora V, Bajwa SJ, Kaur J. Look alike drug labels: A worrying issue. Indian J Anaesth 2011;55:428.

5. Kothari D, Gupta S, Sharma C, Kothari S. Medication error in anaesthesia and critical care: A cause for concern. Indian J Anaesth 2010;54:187-92.

6. Jones JW, Davis AT. Stability of bupivacaine hydrochloride in polypropylene syringes. Am J Hosp Pharm 1993;50:2364-5.

7. Makwana S, Basu B, Makasana Y, Dharamsi A. Prefilled

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syringes: An innovation in parenteral packaging. Int J Pharm Investig 2011;1:200-6.

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DOI:

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How to cite this article: Alam M. Spinal needle with prefilled syringe to prevent medication error: A proposal. Indian J Anaesth

2016;60:525-7.

Post‑operative pneumothorax

with subcutaneous emphysema

in a pre‑eclamptic patient

Sir,

A 30-year-old female patient presented with severe pre-eclampsia for emergency caesarean section. On the operating table, she had a blood pressure (BP) of 176/98 mm Hg, pulse rate 102/min, oxygen saturation (SpO 2 ) 99% and air entry was equal bilaterally.

Rapid sequence induction and intubation were performed; gentle laryngoscopy was performed and cuffed endotracheal tube (ETT), 7.5 internal diameter

was inserted aided by a stylet. The depth of anaesthesia

was maintained with O 2 , nitrous oxide, isoflurane and

muscle relaxant vecuronium (total dose of 6 mg) was used. The monitors used were electrocardiograph, pulse oximeter, non-invasive BP, and end-tidal carbon

dioxide (CO 2 ) monitor. The patient was ventilated on closed circuit with mechanical ventilation (volume control mode with respiratory rate [RR] 12/min, tidal volume of 450 ml, without positive end-expiratory pressure (PEEP), with mean airway pressure of 14

cm

H 2 O). Intra-operative period was uneventful.

The

surgery was completed in 1 h. Postoperatively,

the

neuromuscular blockade was reversed with

neostigmine 2.5 mg intravenous (iv), glycopyrrolate 0.5 mg iv. Due to inadequate reversal of neuromuscular blockade as suspected by poor respiratory efforts, the

reversal drugs were supplemented. Arterial blood gas report showed normal partial pressure of oxygen and potential of hydrogen. However, CO 2 retention was present, so we continued to manually assist her ventilation.

After 10 min, her respiratory efforts were adequate, but her protective airway reflexes were blunted and she was tolerating the ETT well. Therefore, we decided not to extubate the trachea. While shifting the patient to recovery room on T piece, she had a violent coughing and retching episode after which she became restless and developed bradycardia with SpO 2 decreasing to 82%. We then noticed palpable crepitus all over the chest, face and doubtful air entry on chest auscultation. As we suspected displacement of ETT, we extubated the trachea. She was unable to maintain adequate respiratory efforts. Hence, we paralysed her and reintubated her trachea. Thereafter, her vital signs stabilised. Air entry on the left side was decreased. She was shifted to the Intensive Care Unit (ICU) for mechanical ventilation. A chest X-ray was done in the ICU, which showed left-sided pneumothorax with subcutaneous emphysema. An intercostal chest drain was inserted and patient. The patient was maintained ventilatory support without delay (volume control mode with RR 14/min, TV 450 ml, PEEP of 0 cm H 2 O, inspiratory to expiratory ratio (I: E ratio) of 1:2 and peak airway pressures limited to 24 cm H 2 O). We could not find any obvious airway rent as assessed by fibreoptic bronchoscopy. The patient’s relative did not give consent for computed tomography of thorax. After 24 h of stay in the ICU, the patient’s vital signs

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