Hypertensive Crisis During Norepinephrine Syringe Exchange: A Case Report

Area of Science:

• Critical care medicine
• Biomedical engineering
• Clinical pharmacology

Background:

• Syringe pumps are crucial for precise medication delivery in critical care.
• Medication errors, including overdoses, can have severe patient consequences.
• Norepinephrine is a potent vasopressor used to manage life-threatening hypotension.

Observation:

• A patient experienced a hypertensive crisis due to a norepinephrine overdose from a syringe pump malfunction.
• The malfunction occurred during a syringe exchange when the pump repeatedly reported an error.
• An object interfering with the plunger-syringe driver interface was hypothesized as the cause.

Findings:

• In vitro testing confirmed that an object can cause significant peak dosing errors (up to +572%).
• Using an intravenous line clamp resulted in a moderate overdose (0.07 mL, +225%).
• Without a clamp, a large overdose (0.8 mL, +2700%) occurred, demonstrating the critical role of clamping.

Implications:

• Clinicians must be aware of potential syringe pump errors during medication administration.
• Implementing a clamp on the intravenous line during syringe changes can mitigate overdose risks.
• Further investigation into syringe pump error mechanisms and prevention strategies is warranted.