EDITOR:
We would like to report a ‘near-miss’ incident that occurred in our hospital recently.
A 14-yr-old male was receiving an intravenous (i.v.) remifentanil infusion for intraoperative analgesia during a Laparoscopic Cholecystectomy. The procedure had been uneventful with the remifentanil infusing at 21 mL h−1 (0.2 μg kg−1 min−1) from a Monoject* 50-mL syringe (Tyco Healthcare, Gosport, UK) mounted on an IVAC® P3000 syringe driver (Alaris™ Medical Systems, Basingstoke, UK) via a dedicated 22-G cannula on the dorsum of the hand. After 90 min, the syringe driver alarm began to sound and displayed an ‘occlusion’ error message. The syringe, line and i.v. site were checked visually and no occlusion was noted. It was only on closer inspection that two caps from a Lectro-Cath 150 cm i.v. extension set (Vygon UK Ltd, Cirencester, UK, ref. 1155.15) were seen to be obstructing the syringe driver’s mechanism (Fig. 1). The offending caps were removed and the case was completed with no further incident.
Figure 1 Two caps of the extension set obstructing the syringe driver’s mechanism.
The potential of foreign bodies to obstruct anaesthetic breathing equipment has been widely publicized since a fatal incident in 2001 [1]. However, this is not a new phenomenon and there are similar reports from as early as 1962 [Reference Carter2]. We performed a PubMed literature search and noted that fluid administration set blockage and syringe driver malfunction have been reported previously [Reference Pratt3,Reference Bergman, Kluger and Short4]. To our knowledge, this is the first reported case of obstruction of a syringe driver’s mechanism by a foreign body.
To reduce the chances of a similar incident occurring, we recommend the following actions:
• A thorough check of all equipment planned to be used prior to starting the case. Currently, the Association of Anaesthetist’s guidelines for checking anaesthetic equipment concentrate on the anaesthetic machine, monitoring and associated breathing system items [5]. It makes no mention of infusion devices.
• Adherence to the Medical Devices Agency advice that ‘Immediately after removal, the protective caps of intravenous administration sets and other items must be disposed of in an appropriate container’ [1].
• A reduction in the amount of ‘non-essential’ pieces of plastic, including caps and packaging that seem to accompany all medical equipment. The Lectro-Cath 150 cm i.v. extension set (Vygon UK Ltd) comes in two plastic bags and is accompanied by two caps and four plastic clips. This would not only help our patients in the short term, but would also have longer-term beneficial effects on the environment.
• Improved design of infusion devices to incorporate a cover for the moving parts.
Luckily, there was no untoward clinical sequela resulting from this incident. However, syringe driver failure in another clinical setting, for example during a total i.v. technique, or when inotropes were required, may have resulted in a more serious incident. We have reported this incident at our local Morbidity and Mortality Meeting, and to the Medicines and Healthcare products Regulation Agency (MHRA).
