Prevention of Accidental IV Injection into Epidural Tubing

Mushtaque M. Juneja, M.D., EEA.R.C.S.; William E. Ackerman, M.D.

To the Editor

In the perioperative period, patients usually have one or more intravenous infusions. Furthermore continuous epidural infusion of local anesthetics or narcotics is becoming an increasing popular practice for providing adequate analgesia for labor as well as for postoperative surgical pain relief. When using this technique, intravenous tubing is connected to a pump and is attached to the end of an epidural catheter.

Figure 1. Intact Monoject needle on left and standard I.V. tubing injection port.

Drugs like thiopental (1), magnesium sulfate (2), and potassium chloride (3) have been injected into the epidural space through the wrong tubing by accident. To prevent such accidents, different methods have been suggested: e.g. wrapping of tape on all injection ports(2), special continuous infusion sets without injection ports (4), or use of rigid pressure tubing without any ports (5). However, many large hospitals have contracts for specific infusion pumps and infusion sets for continuous epidural infusion for lengthy periods of time and, for economic reasons, practitioners must use the available pump and the tubing set that has intravenous injection ports.

We report another simple method of covering injection ports which should help to reduce the incidence of accidental injection of unintended and potentially dangerous drugs into the epidural space

Figure 2. Cap from Monoject needle removed and used to cover and thus protect injection port in tubing connected to epidural catheter.

The standard Monoject hypodermic needle comes in a plastic container as shown in Figure 1. The upper white part (cap) of the needle container is detached easily and this cap fits snugly on standard injection ports as shown in Figure 2. We use this method to protect the tubing ports on continuous epidural infusions from accidental injection.

Intraoperatively, this method of protecting injection ports can also be useful. It is common for anesthetists to attach I.V. tubing to precordial stethoscopes to listen to breath sounds. This extension tubing usually also has two injection ports. It is our clinical impression that an occasional drug intended for intravenous infusion has been accidentally injected into the injection port of the stethoscope tubing instead of the patient’s I.V. fine injection ports. This needle cap placed on these ports in the stethoscope tubing may prevent these accidents as well as the more serious ones involving epidural catheters.

Mushtaque M. Juneja, M.D., EEA.R.C.S., William E. Ackerman, M.D., Department of Anesthesia, University of Cincinnati College of Medicine, Cincinnati, Ohio

References

  1. Forester JE, Raj PP. Inadvertent epidural injection of thiopental: a case report. Anesth Analg 1975: 406-7.
  2. Dror A, Henriksen E. Accidental epidural magnesium sulfate injection. Anesth Analg 1987: 66:1020-1.
  3. Lin D, Becker K, Shapiro HM. Neurologic changes following epidural injection of potassium chloride and diazepam: a case report with laboratory correlation. Anesthesiology 1986: 65:210-2.
  4. Fromme Ga, Atchison SR. Safety of continuous epidural infusions (Letter). Anesthesiology 1987. 66:94.
  5. Zylanoff P. Safe continuous epidural infusions (Letter). Anesthesiology 1987: 66:94-5.

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