Case 21: Potential Disaster: An Intravenous Line That Stops Working in the Perioperative Phase

Abstract

A 10-year-old boy (30 lb) is scheduled for a left hernia repair. His medical history is otherwise unremarkable. The patient has no known drug allergies, and the family history is negative for anesthesia-related problems. An intravenous (IV) line (20 gauge) in the back of the hand is seen to be adequate; it was placed by the pediatric resident for preoperative IV antibiotic. The patient is taken to the operating room, and monitoring equipment is placed on the child (electrocardiogram [ECG], pulse oximeter, a nerve stimulator, noninvasive blood pressure [BP], and precordial stethoscope). General anesthesia is induced with propofol, 75 mg, and the patient falls asleep. The patient is easily ventilated via a face mask with sevoflurane 1–4 % with 100 % oxygen, and vecuronium, 4 mg, is given by the 20 gauge IV. After 3 min, the nerve stimulator indicates that the patient is not adequately relaxed. The IV is checked and found to be nonfunctioning. A new IV is inserted and a repeat dose of vecuronium is administered. Within 3 min, the patient is adequately relaxed, and an endotracheal tube (ETT) is inserted into the trachea atraumatically. Breath sounds are equal bilaterally. Anesthesia is maintained with nitrous oxide 70 % in oxygen with isoflurane 0.6 % and with meperidine, 15 mg. The surgery commences and concludes uneventfully. At the end of the surgery, with the patient breathing spontaneously, the ETT is removed from the patient’s trachea. The child is taken to the postanesthesia care unit (PACU) asleep but arousable. Twenty minutes later, when you are about to induce anesthesia in your next case, you get a call from the PACU. You are told that your previous patient is not breathing and the oxygen saturation is now 76 %. You tell the nurse to commence artificial ventilation and you run to the PACU. In the PACU, the nurse is successfully administering oxygen 100 % via a face mask using a Jackson Rees modification of the Ayres T-piece. The oxygen saturation is now 96 %, and his vital signs include a heart rate of 140 beats per minute (bpm) and a BP of 80/50 mmHg.