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Letters to Editor

3. BithalPK, PandiaMP, ChouhanRS, PrabhakarH, RathGP,
DashHH, etal. Effects of phenytoin therapy on bispectral
index and haemodynamic changes following induction and
tracheal intubation. Indian J Anaesth 2009;53:18792.
4. SahooS, KaurM, SawhneyC, MishraA. An unusual cause
of delayed recovery from anesthesia. JAnaesthesiol Clin
Pharmacol 2012;28:4156.
5. MorganGE, MikhailMS, MurrayMJ. Neuromuscular blocking
agents. In: Clinical Anesthesiology. 4thed. NewYork: Lange
Medical Books; 2009. p.2246.
6. Levati A, Savoia G, Zoppi F, Boselli L, TommasinoC.
Perioperative prophylaxis with phenytoin: Dosage
and therapeutic plasma levels. Acta Neurochir (Wien)
1996;138:2748.
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DOI:
10.4103/0019-5049.147188
Fatal drug errors in anaesthesia:
Can we override?
Sir,
The drug errors in anaesthesia can be fatal. In spite
of extensive research and protocols to decrease the
errors in drug delivery, major incidents resulting from
injecting a wrong drug from similar looking preparation
of another are reported. We report a case of successful
treatment of hyperkalaemic cardiac arrest(due to
accidental injection of potassium chloride) in a patient
of coronary artery disease with triple vessel disease, who
underwent coronary artery bypass grafting(CABG), by
use of haemofiltration and cardiac massage.
given intravenously. After achieving muscle relaxation
with 8mg of vecuronium bromide, trachea was
intubated with cuffed endotracheal tube of size 8.0.
Right internal jugular vein was cannulated using a 7
Fr triple lumen catheter. Anaesthesia was maintained
using O2/N2O/0.61% isoflurane, with infusions of
fentanyl and vecuronium bromide. The preoperative
and intraoperative arterial blood gas (ABG) and
electrolytes were within normal range. The patient
remained haemodynamically stable. The procedure
of sternotomy, left internal mammary artery resection
and distal grafting of left anterior descending artery
and right coronary artery(RCA) were uneventful.
While the surgeon was performing proximal RCA
graft, ABG revealed metabolic acidosis with pH7.2,
HCO318 meq/L, base excess 5 and serum K+5.0 meq/L.
Sodium bicarbonate 30 meq was administered
slowly. Within minutes, the heart arrested in
diastole. Surgeons found the heart to be very flabby.
The open cardiac massage was ineffective. The
cardiopulmonary resuscitation was started, and three
successive doses of 1mg of adrenaline were given
IV, but there was no response. In the meantime, ABG
was sent and report revealed serum K+of 9.0 meq/L.
Injection calcium chloride 1g, injection furosemide
40mg and injection sodium bicarbonate 50 meq were
given IV slowly. Aglucoseinsulin drip(25% dextrose
with 12 units of insulin) was rapidly administered,
and the patient was hyperventilated. The serum
K+was still very high(8.0 meq/L). Within minutes,
the cardiopulmonary bypass(CPB) pump was
assembled and cardiac massage was continued until
the patient was connected to CPB and haemofiltration
was started.

A 56yearold, 60kg, male was scheduled for CABG. He

had a history of hypertension for the past 7years and was
taking angiotensin receptor blockers and betablockers.
The laboratory investigations were within normal
limits(including electrolytesNa+140 meq/L and
K+4.1 meq/L).

In the operation theatre, monitoring with

electrocardiogram, noninvasive blood pressure(BP),
Bispectral Index (BIS), arterial BP and SpO2 was
started, and two 16 G intravenous(IV) lines were
secured. Anaesthesia was induced using injection Figure 1: Two similar looking ampoules of sodium bicarbonate and
fentanyl 200 cg, midazolam 2mg and propofol 80mg potassium chloride

Indian Journal of Anaesthesia | Vol. 58 | Issue 6 | Nov-Dec 2014 785

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Letters to Editor
When the K+level reverted back to 5.0 meq/L, rewarming
was started, and heart started beating but the rhythm
was irregular. Ashock of 10 joules was given, and the
rhythm was restored to sinus rhythm. The patient was
taken offpump on inotropes, injection adrenaline
0.03mcg/kg/min, injection nitroglycerine 3mcg/kg/
min and injection milrinone 0.5mcg/kg/min. The
BIS revealed a level of 45. The patient was extubated
after the successful maintenance of haemodynamics
and oxygenation parameters. The patient did not have
any neurological impairment, and magnetic resonance
imaging of the brain revealed a normal study.
On enquiring, it was found that potassium chloride was
inadvertently loaded in place of sodium bicarbonate as
the new batch of potassium chloride ampoules were very
similar to ampoules of sodium bicarbonate [Figure1].
This case highlights the human error which resulted
inadvertent loading of the wrong drug, which resulted
in hyperkalaemia. Use of colour coded labels have
resulted in a decrease in the drug errors(P=0.04).
[1]
As per American Society for Testing and Materials
International Standard D4774, nine classes of drugs
commonly used in anaesthesia practice, had a standard
background colour established for userapplied syringe
labels. For these drugs, colour of the containers
top, label border, and any other coloured area on
the label, excluding the background, as required for
maximum contrast, should correspond to the drugs
classification.[2]
It has been observed that human errors are often due to
perceptual confusions. They distinguish information
as per the expectation, although the information may
not be what is expected.[3] It is a possible causal factor
for drug errors comprising drugs with lookalike labels
and packing or lookalike, soundalike(LASA) drug
names.[4,5] Mechanism suggested for this confusion is
that, when a person frequently handles many drugs,
he becomes familiar with their colour coding scheme;
but when he encounters a wrong drug with a LASA
name, he follows his instinct and perceives the LASA
drug as the envisioned drug. Due to the stress and
frequent handling of drugs, medical professionals are
susceptible to this perceptual bias.[5] Message is read
the label twice before you load the drug.
Amitabh Kumar, Kapil Gupta,
Manju Gupta1, Shyam Bhandari
Department of Anaesthesia, VMMC and Safdarjung Hospital,
1
Department of Cardiothoracic and Vascular Surgery, VMMC and
Safdarjung Hospital, New Delhi, India
786
Address for correspondence:
Dr.Amitabh Kumar,
Department of Anaesthesia, VMMC and Safdarjung Hospital,
NewDelhi 110029, India.
Email:dramitabhkumar1980@gmail.com
REFERENCES
1. FastingS, GisvoldSE. Adverse drug errors in anesthesia,
and the impact of coloured syringe labels. Can J Anaesth
2000;47:10607.
2. American Society for Testing and Materials. ASTM D477406
Standard Specification for User Applied Drug Labels in
Anesthesiology. Conshohocken, PA: ASTM International.
Available from: http://www.astm.org/Standards/D4774.htm.
3. ShorrockST. Errors of perception in air traffic control. Saf Sci
2007;45:890904.
4. CohenMR, KiloCM. Highalert medications: Safeguarding
against errors. In: CohenMR, editor. Medication Errors. Vol.5.
Washington, DC: American Pharmaceutical Association;
1999. p.140.
5. DavisNM. Combating confirmation bias. Am J Nurs
1994;94:17.
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Website:
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DOI:
10.4103/0019-5049.147189
Coiling of guide wire in the
internal jugular vein during
central venous catheter insertion:
A rare complication
Sir,
Central venous catheters(CVC) are traditionally used
for access in the intensive care unit setting and in burn
patients for monitoring central venous pressure,[1] for
total parenteral nutrition(TPN),[2] and for rapid volume
replacement during shock. Much has been written
regarding the complications of CVC.[3,4] The rate of
major and minor CVC complications is up to 10%. These
complications include arterial puncture, haematoma,
pneumothorax, haemothorax, chylothorax, brachial
plexus injury, arrhythmias, air embolism, catheter
malposition, and catheter knotting. Gladwin et al.
have reported that the incidence of axillary vein
or right atrial catheter malposition is 14% during
internal jugular venous catheterisation[5] whereas
the overall rate of noninfectious complications of
Indian Journal of Anaesthesia | Vol. 58 | Issue 6 | Nov-Dec 2014