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Blocked intravenous line during Rapid Sequence Induction | Error | Problem | Discussion | Solution | Anesthetic case management |

Case History

An 8 years old (previously healthy body-30 kg) is scheduled for an Emergency appendectomy 

patient is taken to the OR , an intravenous IV line 20 G in the antecubital fosaa has already

been started in the emergency room and is working fine 

Routine monitoring equipment is placed on the child 

Electrocardiogram (ECG)

-Pulse oximeter

-Precordial stethoscope 

-Non invasive blood pressure cuff 

Anesthesia Management (General Anesthesia)

Induction : Thiopentone 100mg

Rocuronium 20mg (with cricoid pressure)

Error

Precipitation is noted in the IV tubing and the precipitation is so severe that

the IV is completely occluded.

The patient is asleep , but no effect of neuromuscular relaxation , as per nerve stimulator 

is seen after 90 second 

You attempt laryngoscopy but failed to see the epiglottis because the child is moving his

head and upper limbs. Vital signs remains stable

QUESTION ?

WHAT WILL YOU DO NOW ?

SOLUTIONS:

  1. Maintain cricoid pressure
  2. Give succinylcholine under the tounge in the usual IV dose.
  3. The onset is as quick as IV succinylcholine.
  4. Intramuscular (IM) injection of the drug could also be used but the onset is longer than sublingual administration (It takes at least 2 minute for the full effect of IM succinylcholine to take place

Discussion 

Rocuronium has been considered an appropriate alternative to the succinylcholine in certain circumstances when Rapid sequence induction is indicated 

Unfortunately if mixing of Rocuronium and Thiopentone does occur , a dense white precipitation forms withing the IV tubing . This precipitation has been known to cause complete obstruction of flow.

 

Recommendation

If thiopental and Rocuronium are  used together , as in rapid sequence technique

  1. It is imperative to flush the IV thiopentol with the carrier fluid before rocuronium is given.
  2. This can be done by saline flush or by squeezing the blub on a blood giving set 
  3. If one does not have a free owing IV , an alternate induction agent or succinylcholine should be considered. 
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