The syringe said mepivacaine. It was potassium.

The Anesthesia Brief  ·  Issue #9

If you're thinking it, we're talking about it.

By Marc Smith, DNP, CRNA & Shantall Ruiz Cummins, DNP, CRNA

Six things worth knowing today. Let's get into it.

The syringe said mepivacaine. It was potassium.

Three weeks, no Brief. We were traveling, our IT guy was traveling too, and the whole thing quietly broke while nobody was watching. A show about work-life balance, losing three weeks to work-life balance. We hear it. We're working on it, we'll get there, and we're glad you're still here.

Here's what happened while we were out, starting with what's sitting on your cart.

On August 14, four joint replacement patients at Ascension Saint Thomas Midtown in Nashville got spinals from syringes labeled mepivacaine 2%. The syringes held potassium phosphate. Two of those patients are paralyzed, one went into cardiac arrest, and one is on ECMO. Nobody has died as of Monday night, and we're saying that carefully, because one of them is still critical.

The state put out an 80-page report on how it happened, and it reads worse than the headline. A pharmacy tech pulled from the wrong bin. The barcode scan rejected the vial, and the system allowed a manual override, no pharmacist needed. Three techs and a pharmacist handled those syringes and nobody caught it. They went up to the OR with the wrong label, and the last person holding one had no way to see what was inside.

Spinals are not suddenly dangerous, and not everybody works with pharmacy-prepared syringes. Drawing up your own from a vial is a different thing. But all of us are trusting somebody, that the manufacturer filled the vial right, that whatever pharmacy mixed is what the label says, and sometimes there is no way to catch an error like this at the bedside. What you can check is the system behind it, and that's this week's ask.

Our take is at the bottom of this issue ↓

Ask pharmacy the override question

Read the state's findings on the Nashville error, then ask your pharmacy one question, when a barcode scan alert fires during sterile prep, can it be overridden without a pharmacist? In Nashville the scan caught the wrong vial and a manual override beat it. The answer to that question is the distance between their pharmacy and yours.

A scope docket where nothing moved

Nothing moved this week on scope, so here is where things actually stand. New York's certification bills, S02302 and S00357, are still sitting with no action since early January, so Albany owes you patience, not a party. The June wins in Ohio, Arizona, and Rhode Island are settled law and unchanged, Delaware's HB435 advanced but is not law yet, and the federal Medicare Access to Rural Anesthesiology Act is still pending after mid-July action. Read your state's bill on LegiScan and tell your association where you stand.

→ Full scope tracker + your state

The locals are short all at once

Heads up for block days, ropivacaine, bupivacaine, lidocaine, ketorolac, and lorazepam are all on the FDA shortage list right now, every one of them a mixed picture, some presentations available, some limited, some unavailable. Mixed means your shelf is the only status that matters. Confirm with pharmacy what's actually in stock and pick your substitute and dose before the first case, not during it.

→ Full shortage list

Ventilating a difficult airway without touching it

Imagine keeping a predicted difficult airway ventilated during induction without pushing any gas through the airway. That's the idea behind negative pressure ventilation. Think iron lung, shrunk to a modern shell around the chest. Instead of blowing air down the airway, it gently pulls the chest wall outward, and air follows on its own, the way a normal breath works. A feasibility study in the British Journal of Anaesthesia just tested it during induction in predicted difficult airways, and feasibility means can it be done, not change your practice, so file this one under watch, not adopt.

→ Tech watch

On the last set of hands

A pharmacy error is the official finding, and we believe it. But here's the part nobody puts in a report. If a syringe like that ever reaches your hand, the harm lands through you. Not your error, your hands. That's a weight the official finding doesn't touch, and every one of us who pushes drugs for a living understands it without being told.

So our take is the boring kind of brave, be the person who asks the override question out loud, in a meeting, with names in the room. Nashville didn't lack technology. It lacked one person willing to be inconvenient before the harm instead of haunted after it. Be that person. Nobody claps for the disaster that never happened, but that's the job, and it has always been the job.

- Marc & Shantall

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Legislative data, LegiScan & OpenStates (CC BY 4.0). Drug shortage data, ASHP / openFDA. Federal regulatory data, FederalRegister.gov (public domain). Compensation, Marit Health, BLS, AANA.

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