Inadvertent Epidural and Intravenous Line Swap: A Case Report.

Administration of medication via the wrong administration route has the potential for serious morbidity and mortality. Regrettably, because of the ethical implications in such situations, most of our knowledge comes from case reports. This paper reports on the accidental misconnection of intravenous acetaminophen to an epidural line and of the patient-controlled epidural analgesia (PCEA) pump to intravenous access, as a result of patient error. A male patient aged 60-65 years, 80 kg, American Society of Anesthesiologists (ASA) physical status III presented for unilateral total knee arthroplasty under a combined spinal-epidural anaesthesia technique. For postoperative analgesia, a multimodal analgesia regimen including acetaminophen, in combination with a PCEA pump, was selected. During the night, the patient disconnected and reconnected the drug administration lines, resulting in an epidural/intravenous misconnection. After six unsupervised hours, a total of 114 mg of ropivacaine was administered intravenously and the acetaminophen vial, at this time connected to the epidural catheter, was found empty. A full physical examination by the on-call anaesthesiologist showed no abnormal findings and the nursing staff and patient were instructed on signs to look out for and how to monitor for complications. This case highlights the risks associated with intravenous/epidural line misconnection, as well as the impactful variable the patient represents when admitted to a lower vigilance infirmary. This makes it evident that more safety developments are needed to ensure the utmost quality of care is provided to all patients.

Fluid Leak From the Spinal-Epidural Puncture Site: Is That Cerebrospinal Fluid?

We present the case of a 30-year-old parturient who underwent a combined spinal-epidural for an elective cesarean section and subsequently experienced fluid leakage at the puncture site. The fluid analysis indicated a glucose level of 57 mg/dL, which initially raised suspicion of a cerebrospinal fluid fistula. However, an MRI revealed no significant abnormalities, and the patient remained asymptomatic. We aim to highlight that various fluids can emerge from a neuraxial puncture site, including cerebrospinal fluid, interstitial fluid due to edema, or residual local anesthetic. While glucose measurement has been used for diagnosing cerebrospinal fluid leakage, its reliability is questionable. More dependable diagnostic tests can be used such as the measurement of beta-trace protein or beta-2-transferrin or MRI.

Alternative Postoperative Analgesia Technique for Peripheral Vascular Revascularization: A Case Report.

Peripheral arterial disease (PAD) patients often require surgical peripheral vascular revascularization (PVR), in which postoperative pain management can be challenging. This case report details a 43-year-old female patient with PAD who underwent urgent femoral popliteal bypass with an inverted ipsilateral great saphenous vein and left femoral endarterectomy. Due to contraindications for neuraxial anesthesia and the necessity for continuous anticoagulation, the procedure was performed under general anesthesia (GA) and an unconventional technique with intraoperative perineural catheter (PC) placement to guarantee adequate postoperative analgesia. The surgeon inserted the PC in the vicinity of the femoral nerve under direct visualization before surgical closure. Postoperative analgesia was successfully managed, demonstrating the effectiveness of this approach as part of a multimodal analgesia strategy. This case report suggests that such a technique, supervised by an anesthesiologist and supported by a multidisciplinary team, can provide effective postoperative pain control in PAD patients without interrupting perioperative anticoagulation. Formal protocols for similar procedures can arise, incorporating this analgesic option.