Reactions 1112 - 29 Jul 2006

Bupivacaine/fentanyl

Difficulty breathing and chest numbness followingan error with an epidural infusion pump: case report

A 32-year-old gravida 2 para 1 woman underwentplacement of an epidural catheter and a 10mL bolus of 0.25%bupivacaine was administered incrementally, withoutincident. The epidural tubing was primed with 0.0625%bupivacaine containing fentanyl 2 µg/mL (250mL bag total)and the tubing was inserted into an infusion pump. Shereported difficulty breathing and chest numbnessapproximately 2 hours after epidural insertion. Onexamination, she had normal BP, a good grip strength and a T4sensory level to cold test; no fetal HR abnormalities weredetected. The epidural infusion bag was empty and the flowregulator and infusion pump door were open. Her epiduralinfusion was stopped temporarily, and she delivered a healthybaby, without adverse sequelae.

Author comment: "The situation noted seems to be dueto an interaction between a human error and the design ofthe infusion pump."Ghosh K, et al. An error associated with an epidural drug infusion pump.Anesthesiology 105: 226, No. 1, Jul 2006 - USA 801041632

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Reactions 29 Jul 2006 No. 11120114-9954/10/1112-0001/$14.95 Adis © 2010 Springer International Publishing AG. All rights reserved