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Table of Contents
LETTER TO EDITOR
Year : 2014  |  Volume : 30  |  Issue : 4  |  Page : 579-581

Malfunctioning Pediatric infusion set leading to accidental fluid overload and pulmonary edema


Department of Anaesthesiology Mahatma Gandhi Institute of Medical Sciences, Sewagram, Wardha, Maharashtra, India

Date of Web Publication14-Oct-2014

Correspondence Address:
Dhiraj B Bhandari
Department of Anaesthesiology, Mahatma Gandhi Institute of Medical Sciences, Sewagram - 442 102, Wardha, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9185.142881

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How to cite this article:
Bhandari DB, Mahalle AR, Premendran BJ, Dhande PS. Malfunctioning Pediatric infusion set leading to accidental fluid overload and pulmonary edema . J Anaesthesiol Clin Pharmacol 2014;30:579-81

How to cite this URL:
Bhandari DB, Mahalle AR, Premendran BJ, Dhande PS. Malfunctioning Pediatric infusion set leading to accidental fluid overload and pulmonary edema . J Anaesthesiol Clin Pharmacol [serial online] 2014 [cited 2019 Nov 12];30:579-81. Available from: http://www.joacp.org/text.asp?2014/30/4/579/142881

Sir,

Despite continuous strive for improved patient safety, there can be situations in complex environments like operation theatre, where even seemingly innumerable small mishaps can culminate eventually into major disaster. Most mishaps are of multifactorial causes, but human errors and lack of team work contribute significantly. [1],[2]

A 4-year-old American Society of Anaesthesiology class IE 14 Kg child posted for emergency eyelid surgery repair surgery developed pulmonary edema due to accidental fluid overload because of a malfunctioning pediatric drip−burette set. Not only equipment failure, but also subpar vigilance of the anesthesia provider led to the complication.

After an uneventful pre- and intraoperative period, at the end of the case, prior to extubation, child was diagnosed to have pulmonary edema based on the findings of frothy secretions from endotracheal tube, presence of bilateral crepitations in lung fields and oxygen desaturation [Figure 2]. Further, it came to notice that the child had received around 400 ml intravenous fluid. It was found that clamp of the pedia-drip set located between the donor intravenous fluid bottle and the recipient "infusion bottle" of pedia-drip was malfunctioning and continuously fluid was being auto charged into the "infusion bottle," from where the fluid was being given to patient [Figure 1]. Fluid levels were gradually lowered in infusion bottle to give a sense of pseudo security of fluid being delivered at appropriate rate, whereas the fluid being delivered was at much higher rate. Thus, accidental fluid overload i.e. approx 400 ml in an hour (versus a planned approximate of 75 ml/ 1st hour: 2 hours NPO) led to pulmonary edema. The child was treated successfully with positive pressure ventilation, intravenous lasix (single dose of 0.5 mg/kg) and extubated 2 h later and discharged from hospital without any morbidity.
Figure 1: Arrow shows the malfunctioning clamp between the charging and the recipient section of the pediatric infusion set

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Figure 2: X-ray of patient taken after extubation

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Anesthetic equipments have key role in administering anesthesia but also have tendency to fail and harm patients. Anesthesiologists have the primary and utmost responsibility to prevent this.

In a recent report, monitoring equipments (39.8%), ventilators (17.9%), leaks (9.6%), infusion pumps (5.2%), and other minor miscellaneous errors (9.3%) were identified as major equipment failures during anesthesia. Though equipment failure was present, user error or unfamiliarity also played a part in the mishaps. [3]

Anesthesiology has been looked upon as a role model amongst medical specialties, which constantly strives for improved patient safety. The success of incident reporting and improving safety in high-risk industries like aviation is known but has not yet sufficiently percolated into field of medicine and more so in developing countries like India. The perceived problems in reporting critical incidents have been described as fear of punitive action, lack of organizational support, lack of understanding in clinicians as to what to report, how will be report analyzed and its benefits. [4] In some developing countries, it is a big challenge as there is no clear authority to report to.

To conclude, there can be no shortcuts to good clinical monitoring and vigilance during administration of anesthesia. Incident reporting and analysis systems should be encouraged for improving patient safety.

 
  References Top

1.
Haller G, Laroche T, Clergue F. Morbidity in anaesthesia: Today and tomorrow. Best Pract Res Clin Anaesthesiol 2011;25:123-32.  Back to cited text no. 1
    
2.
Gravenstein JS. How does human error affect safety in anaesthesia? Surg Oncol Clin N Am 2000;9:81-95.  Back to cited text no. 2
[PUBMED]    
3.
Cassidy CJ, Smith A, Arnot-Smith J. Critical incident reports concerning anaesthetic equipment: Analysis of the UK National Reporting and Learning System (NRLS) data from 2006-2008*. Anaesthesia 2011;66:879-88.  Back to cited text no. 3
    
4.
Mahajan RP. Critical incident reporting and learning. Br J Anaesth 2010;105:69-75.  Back to cited text no. 4
[PUBMED]    


    Figures

  [Figure 1], [Figure 2]



 

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