Downloaded from http://journals.lww.com/ejanaesthesiology by BhDMf5ePHKbH4TTImqenVBaqevB2sTM00jGUR1GXzzTKl+Bw2E+KxfQnJzLLLYeL3v9sTycIar0= on 10/03/2020 Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited. REVIEW ARTICLE Erroneous neuraxial administration of neuromuscular blocking drugs Clinical and human factors analysis Santosh Patel BACKGROUND Drug errors during neuraxial anaesthesia or analgesia are not well known. OBJECTIVES To review the clinical consequences associ- ated with incorrect administration of neuromuscular blocking drugs (NMBDs) during spinal or epidural anaesthesia, and to investigate human factors and strategies available to help prevent such errors. DESIGN A review of reports of neuraxial administration of NMBDs in humans. DATA SOURCES Published reports of errors involving NMBDs. We searched the period between 1965 and 2019. ELIGIBILITY CRITERIA Error reports in any language. Non- neuraxial drug errors were excluded. RESULTS We identified 20 reports involving seven different NMBDs inadvertently administered via the epidural or intra- thecal routes. All patients developed systemic neuromuscu- lar junction blockade. Fourteen errors occurred while patients were awake. The onset of action was delayed following epidural rocuronium and suxamethonium. The dura- tion of action was prolonged following epidural administra- tion of vecuronium, pancuronium, cisatracrium and suxamethonium. Five patients required emergency airway interventions. Intrethecal gallamine caused convulsions and muscle spasms migrating up the body. Syringe swap was the primary cause for the majority of errors and percep- tual errors were the most common. Implementation of recom- mendations could have prevented the errors. CONCLUSION Following the epidural injection of NMBDs the effects are delayed and prolonged. There was no serious morbidity reported following neuraxial administra- tion of the NMBDs used in current practice. Perceptual errors resulting in incorrect syringe choice were the com- monest cause. Four measures can be introduced to reduce such errors. Published online 5 May 2020 Introduction Drug errors are a major safety issue during the peri-opera- tive period. The prevalence of drug administration errors associated with the practice of neuraxial anaesthesia is not well known. Incorrect medication administered during neuraxial procedures may result in devastating conse- quences from both local vascular and neurological effects within the spinal canal as well as more distant effects due to the cephalad spread of the drug within the spinal canal. In addition, systemic effects following systemic reabsorption are a major concern following wrong drug injection via the intrathecal or epidural routes. Previously, we studied the nature of neuraxial drug errors in the obstetric population 1 and also specifically to neuraxial tranexamic acid. 2 Neuromuscular blocking drugs (NMBDs) are com- monly stored and used along with other drugs in operating rooms. Generally, NMBDs do not cross the blood–brain barrier following intravenous administra- tion. However, they may penetrate the central nervous system and cause neurotoxicity in the presence of a damaged blood-brain barrier. The inadvertent adminis- tration of NMBD during intrathecal or epidural anaes- thesia provides an opportunity to learn about their neurological effects as well as their systemic effects by these routes of administration. This review is focused on summarising the clinical effects of neuraxial NMBDs and the human factors involved in the errors and will also Eur J Anaesthesiol 2020; 37:857–863 From the Department of Anaesthesia, Tawam Hospital, Al Ain, Abu Dhabi, UAE Correspondence to Santosh Patel, MD, FRCA, Consultant Anaesthetist, Department of Anaesthesia, Tawam Hospital, Al Ain, Abu Dhabi, UAE E-mail: skpatel@seha.ae 0265-0215 Copyright ß 2020 European Society of Anaesthesiology. All rights reserved. DOI:10.1097/EJA.0000000000001232