Residual drugs in intravenous cannulae and extension lines
Investigation into report of patient who stopped breathing after suxamethonium accidentally flushed through his system few hours post kidney procedure. He recovered few minutes later after manual ventilation; but affected by experience of being awake but unable to move or breathe
Source:
Healthcare Safety Investigation Branch
SPS commentary:
It was highlighted that despite multiple safety alerts being issued over the past ten years, residual drugs in cannulae and extension line events continue to happen. When these events involve drugs that cause the patient to stop breathing, there is a risk of hypoxic brain injury.
The HSIB recommends that the Royal College of Anaesthetists and Centre for Perioperative Care work with relevant stakeholders to review, update and integrate new guidance on the surgical safety checklist 'Sign Out' process. Specifically, the guidance should be updated in relation to the flushing of cannulae and extension lines by strengthening the current administrative barriers, considering the hierarchy of hazard control, and the issues identified by the HSIB investigation.
HSIB also recommends that the Royal College of Anaesthetists reviews its 'Guidelines for the provision of anaesthetic services' regarding the planning and oversight of perianaesthetic care in non-theatre settings.
Updated guidance from the National Infusion and Vascular Access Society (NIVAS) on “line flushing” has just been published. This document is intended to give healthcare professions an overview of the issue of residual medicine volumes in infusion sets, updated guidance on flushing infusion sets, and evidence-based recommendations for best practice.