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Recall after total intravenous anaesthesia due to an equipment misuse
1Department of Anaesthesia, Toronto Hospital, University of Toronto, Ontario, Canada. doris.tong@utoronto.ca
Purpose:
To present a case of recall after total intravenous anaesthesia (TIVA) with propofol-alfentanil infusions to point out an uncommon misuse of the Bard InfusOR syringe driver.
Clinical Features:
A healthy patient underwent diagnostic dilatation and curettage and laparoscopy for lysis of peritoneal adhesions. After induction, anaesthesia was maintained with propofol-alfentanil infusions using the Bard InfusOR syringe drivers. Ten minutes into maintenance, the patient was moving. The flashing green light confirmed delivery of the medication and the alarms were not activated. However, the latch of the movable lever in the propofol syringe driver was found to be improperly positioned at the top of the plunger and only a small amount of propofol had been delivered. Postoperatively, the patient could recall the abdomen being touched during laparoscopy. An explanation was given and the patient was satisfied.
Conclusion:
The Bard InfusOR syringe driver is not designed to detect a malposition of the lever on the syringe plunger. The anaesthetist must ensure proper placement of the lever and visual confirmation of medication delivery in order to prevent awareness due to this particular problem.