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Reliable Acute Care Medicine

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Crisis Management in Acute Care Settings

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Abstract

A patient was prepared to undergo major abdominal surgery and received a thoracic epidural catheter prior to the induction of anesthesia. At the end of the operation, a local anesthetic was given and a PCEA pump was connected in the recovery room. Following an uneventful postoperative course in the postoperative care unit (PACU), the patient was transferred to a general ward. He was awake and had stable vital signs. At 2:00 a.m. the anesthesia resident was paged by the night nurse and told that “either the catheter has become displaced or something’s wrong with the pump.” Further inquiry revealed that the patient complained about increasing pain that could not be relieved by boluses of local anesthetic. Upon arrival, the resident observed a patient who was fully oriented, had noninvasive blood pressure values of 100/50 mmHg, a heart rate of 45 bpm and a saturation of 94%. The anesthetist inspected the insertion site and catheter and realized that the PCEA line was not connected to the filter but instead to the central intravenous line. Because it was difficult to determine when the improper connection occurred, the exact amount of local anesthetic that was injected intravenously was impossible to calculate.

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Editors and Affiliations

  1. Department of Anesthesiology, University of Erlangen, Krankenhausstrasse 12, 91054, Erlangen, Germany

    Michael St. Pierre

  2. Hohenheimerstrasse 104, 71686, Remseck, Germany

    Gesine Hofinger

  3. Woehlerstrasse 12, 10115, Berlin, Germany

    Cornelius Buerschaper

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(2008). Reliable Acute Care Medicine. In: St. Pierre, M., Hofinger, G., Buerschaper, C. (eds) Crisis Management in Acute Care Settings. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-540-71062-2_15

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  • DOI: https://doi.org/10.1007/978-3-540-71062-2_15

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