A 58-year-old man, scheduled for aortoiliac artery bypass graft, had an epidural catheter placed for postoperative pain management. Surgery proceeded uneventfully under general anesthesia. During the closure of the surgical incision, the surgery fellow drew 12 mL of 0.25% bupivacaine (a local anesthetic) into a 12 mL labeled syringe of which 4 mL was injected into the epidural space. The fellow subsequently placed the bupivacaine syringe with the remaining 8 mL of the drug in the pocket of his scrub suit.
Anticipating the conclusion of surgery, the fellow prepared a second 12 mL syringe drawing up 4 mL of neostigmine (4 mg) and 4 mL of glycopyrrolate (0.8 mg) totaling 8 mL and labeled it, adding this syringe to the same pocket of his scrubs. At the conclusion of the surgical procedure, the attending asked the fellow to reverse the neuromuscular block with neostigmine and glycopyrrolate. The fellow pulled a syringe out of his pocket, assumed it contained the neostigmine and glycopyrrolate, and injected 6 mL and then placed the syringe back in his pocket.
After 3 minutes, the patient still appeared weak (i.e., with residual neuromuscular blockade), and the attending requested administration of an additional 1 mg of neostigmine. When the fellow retrieved a syringe from his pocket, he recognized that he had previously pulled the wrong syringe and inadvertently administered bupivacaine, the anesthetic, rather than neostigmine/glycopyrrolate. Once the correct medication was administered, neuromuscular blockade was reversed. Although the patient was not harmed by the erroneous intravenous (IV) administration of bupivacaine, he potentially could have been.
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