Errors associated with the concentration of epinephrine in endonasal surgery
- نوع فایل : کتاب
- زبان : انگلیسی
- مؤلف : Petr Matous.ek . Pavel Kom.پLnek . Anton.پLn Garc.ic
- چاپ و سال / کشور: 2011
Description
This paper presents two cases of using erroneous concentrations of epinephrine during endonasal surgery. The two patients discussed were part of a larger study aimed at monitoring the absorption of epinephrine upon injection into the nasal mucosa. During this study, we observed major cardiovascular reactions in two consecutive patients—ventricular tachycardia with ventricular extrasystole and a significant rise in systolic and diastolic blood pressure and pulse rate. This state required pharmacological intervention. In hindsight, it was found that an erroneous application of ten times higher (1:10,000) concentration of epinephrine than the usual was injected. The applied solution was prepared in our institutional pharmacy and was labelled incorrectly (1:100,000 instead of 1:10,000). The authors have analysed the steps leading to the erroneous applications and recommend safety precautions for the prevention of errors in the concentration levels of epinephrine. Epinephrine injections in concentrations of 1:10,000, followed by analyses of epinephrine levels in venous blood, have not yet been described in available literature.
Eur Arch Otorhinolaryngol (2011) 268:1009–1011, Received: 4 January 2010 / Accepted: 16 November 2010 / Published online: 17 February 2011 Springer-Verlag 2011
