It is common practice for patients admitted to Intensive Care Units to have indwelling intravenous cannulae. Sometimes these cannulae are used only for the administration of drugs and are closed otherwise. Residual drugs in the deadspace of these intravenous cannulae as well as connected stoppers or 3-way stopcocks can later be flushed unknowingly. We would like to report a case in which inadvertent flushing of residual pancuronium caused complete muscle paralysis and respiratory arrest in a young child

Khan, Fazal Hameed

Khan, R. I.

Naqvi, H .I

English

Khan, Robyna Irshad

Naqvi, Hamid Iqil

eCommons@AKU

eCommons@AKUDepartment of Anaesthesia Medical College, PakistanJanuary 2002Respiratory arrest in a child after flushing ofpancuronium from the dead space of intravenouscannulaR. I. KhanAga Khan UniversityFazal Hameed KhanAga Khan University, fazal.hkhan@aku.eduH .I NaqviAga Khan UniversityFollow this and additional works at: http://ecommons.aku.edu/pakistan_fhs_mc_anaesthPart of the Anesthesiology CommonsRecommended CitationKhan, R., Khan, F., Naqvi, H. (2002). Respiratory arrest in a child after flushing of pancuronium from the dead space of intravenouscannula. Journal of Pakistan Medical Association, 52(10), 487-488.Available at: http://ecommons.aku.edu/pakistan_fhs_mc_anaesth/96Respiratory Arrest in a Child after Flushing of Pancuroniumfrom the Deadspace of Intravenous CannulaR. I. Khan,F. H. Khan,H .1. Naqvi ( Department of Anaesthesiology, The Aga Khan UniversityHospital, Karachi. ) Introduction It is common practice for patients admitted to Intensive Care Units to have indwelling intravenouscannulae. Sometimes these cannulae are used only for the administration of drugs and are closedotherwise. Residual drugs in the deadspace of these intravenous cannulae as well as connected stoppersor 3-way stopcocks can later be flushed unknowingly. We would like to report a case in whichinadvertent flushing of residual pancuronium caused complete muscle paralysis and respiratory arrestin a young child.Case Report A 5-month-old female child weighing 4.45 kg was admitted to Intensive Care Unit of our hospital forhypocalcemic seizures that lead to cardiorespiratory arrest. Her trachea was intubated and mechanicalventilation started. After detailed investigations, the final diagnosis of rickets was made. During thecourse of her ICU stay she developed acute respiratory distress syndrome (ARDS) and abdominaldistention. It was difficult to ventilate her with assisted modes of ventilation so controlled ventilationwas instituted using pancuronium for muscle relaxation which was administered in hourly boluses. Shewas treated medically for her problems and on 17th day of intubation, she was finally extubated. Sheremained well and active for 2 hours post extubation. Arterial blood gases done at that time showed apH of 7.38, PCO2 38 mm Hg, P02 98 mm Hg, H2C03 23 meq/L and Sp02 98% on Fi02 of 40% viaoxyhood. During that period she had two 24 G x3/4 11 cannulae in each arm. The cannula on the leftarm was being flushed with continuous intravenous solution, while that on the right arm had a 3 waystopcock (Nipro medical industries limited, Japan) attached to it and was closed with a heplock stopper.Two hours after extubation a nurse flushed the cannula on right arm with saline to keep it patent. Thechild immediately desaturated, became bradycardiac and developed complete flaccid paralysis.Intravenous atropine was given, child’s trachea intubated and bagging with 100% oxygen started.Cardiac rhythm reverted back to normal within 1-2 minutes. Due to the presence of sudden flaccidparalysis without any obvious reason, inadvertent administration of muscle relaxant was suspected. Anerve stimulator demonstrated complete neuromuscular paralysis. She was connected to the ventilatorto facilitate positive pressure ventilation. Neuromuscular function checked at regular intervals showeda typical pattern of gradual reversal from the effects of a non-depolarizing muscle relaxant. The patientregained full muscle power after about one hour and was uneventfully extubated the next morning andlater moved to the ward. Detailed inquiry revealed that the last drug given through the right armcannula via 3 way stopcock prior to flushing with saline was 0.5 mg of pancuronium diluted in 1 ml ofwater injected 6 hours ago. It was concluded that some residual drug remained in the 3-way stopcockand cannula which was later flushed into circulation resulting in apnea of the child.Discussion Increasing awareness about the transmission of diseases through the needlestick injuries or cuts andabrasions on the skin has initiated the physicians today to use cannulae with attached injection ports orheplocks and 3-way stopcocks. However they have their own drawbacks. The volume of drug retainedin the equipment deadspace may result in delivery of an inadequate dose of the drug to the patient. Inaddition, subsequent flushing of these relatively smaller drug volumes has been shown to havesurprisingly active clinical effects1.It is a known fact that between 10 to 30% of 1 ml of intravenous injection may remain in the deadspaceof a cannula or indwelling needle depending on the type and gauge of the equipment used2. Therecommended method of calculating the deadspace of intravenous equipment is to weigh it before andafter filling it with water2 or normal saline1 . Substraction of dry weight from the wet weight is equal tothe deadspace. Weight is converted to volume by assuming 1 gm of 0.9 % normal saline at roomtemperature is equal to 0.995 ml while I gm of sterile water is equal to 1 ml. In order to calculate thecombined deadspace of cannula and 3-way stopcock we used the method described by Maclie andfilled the deadspace of the equipment with sterile water. 10 cannulae (Safelet Cath, Nipro MedicalIndustries limited, Japan) of 24 G x3/4” were taken and separately connected to 10 3-way stopcocks(Nipro Medical Industries Limited, Japan). This equipment was the same as used in the clinical setting.A scale was zeroed after placing a beaker over it. Dry weight of every device was measuredindividually. Wet weight was calculated by filling the apparatus with sterile water. Every possibleprecaution was taken to remove air bubbles and the exterior of the device was carefully dried beforeweighing. To simulate the clinical setting, filling was carried out using 5 ml BD syringe like the oneused in ICU to inject pancuronium. The syringe was removed before measurements. The difference oftwo weights in each device was taken as equivalent to the deadspace which was then converted tovolume. Mean deadspace came out to be 0.20 ml. In our ICU, the routine is to dilute the hourly dose ofa drug in 1 ml of water. In the present instance 0.5 mg of pancuronium was diluted in 1 ml of water.0.20 ml of equipment deadspace contained 0.1 mg of the drug, which in a 4.45 kg weight child was0.022 mg/kg. Although less than the recommended paralysing dose, it was still found sufficient toparalyze her when flushed into the circulation. Several authors have reported that low doses of musclerelaxants can cause distressing symptoms. D-tubocurarine 0.05 mg/kg3, pancuronium 0.014 mg/kg4,atracurium 0.025 mg/kg5 , vecuronium 0.005-0.0 10 mg/kg6 and suxamethonium 0.07 mg/kg7 cancause distressing symptoms such as ptosis, blurring of vision, and difficulty in breathing in a largeproportion of patients, with a measurable degree of respiratory impairment in a significant number ofthem. This effect may become more pronounced in a partially reversed patient or in patients who havereduced respiratory reserve.Similar cases of muscle paralysis have been reported postoperatively in children8 as well as in adults9after flushing of cannulae through which suxamethonium had previously been injected but to ourknowledge, no case has been reported of a similar event in the setting of intensive care unit or wherepancuronium has been used. Physicians working in intensive care units should keep this possibility inmind so that they can intervene early and prevent any fatal complications. We recommend that if 3-waystopcocks or heplock stoppers are being used for administration of drugs in pediatric patients inintensive care units, they should be flushed immediately afterwards with saline or water. We alsosuggest that all unnecessary intravenous lines should be removed whenever possible.References 1.Smart NO. The functional deadspace of needle-free injection ports. Anaesth. Intens. Care, 1991;19:429-33.2.Macfie AG. Equipment deadspace and drug administration. Anaesthesia, 1990; 45: 145-47.3.Bruce DL, Downs JB, Kulkarni PS, et al. Precurarization inhibits maximal ventilatory effort.Anesthesiology, 1984; 61:618-21.4.Rao TLK, Jacobs HK. Pulmonary function following ‘pretreatment’ dose of pancuronium involunteers. Anesth. Analg, 1980; 59:659-61.5.Donati F. The priming saga; where do we stand now? Can. J. Anaesth., 1988; 35:1-4.6.Engbaek J, Howardy-Hansen P, Ording H, et al. Precurarization with vecuronium and pancuronium inawake, healthy volunteers: the influence on neuromuscular transmission and pulmonary function. Acta.Anaesthesiol. Scand., 1985; 29:117-20.7.Schreiber W, Plotz J. Muscular paralysis following IV. regional suxamethonium test. Br. J. Anaesth.,1980; 52:83-84.8.Davidson A, Brown TCK. Respiratory arrest in two children following postoperative flushing ofsuxamethonium from the deadspace of intravenous cannulae. Anaesth. Intens. Care, 1996; 24:97-98.9.Stone RJ. Suxamethonium in the deadspace of an adult’s indwelling intravenous cannula.Anaesthesia, 1993; 48:838.

Respiratory arrest in a child after flushing of pancuronium from the dead space of intravenous cannula

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Respiratory arrest in a child after flushing of pancuronium from the dead space of intravenous cannula

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