Vial Look-Alikes Pose Risks

James G. Chapman, MD

To the Editor

My group does a lot of plastic surgery “office anesthesia.” Recently, I came upon these 2 vial “look-alikes” that are used in almost every case, one by us and the other by the surgeon. We use Decadron very liberally as an IV push—about 2-3 mg. The other, epinephrine (1:1000), is used by the surgeons in their various dilute “local/tumescent” solutions, and could be potentially lethal in certain patients in a 2-3 mg push. I grabbed the epinephrine the other day in preparation for giving the Decadron. Fortunately, I checked the label.

James G. Chapman, MD
Jacksonville, FL