title: [Incorrect programming of a target controlled infusion pump. Case SENSAR of the trimester].
abstract: We report the case of a patient who underwent surgical aortic valve replacement. During general anaesthesia maintenance, the patient received a remifentanyl infusion via a target controlled infusion (TCI) system. The infusion pump that was prepared to deliver the infusion showed malfunction at the beginning of the surgery, so it was quickly replaced with a second pump. After a few minutes into the surgery, the patient presented with hypotension refractory to treatment. The remifentanyl syringe also emptied faster than expected. On reviewing the TCI pump, it was found that it was erroneously programmed for propofol instead of remifentanyl, thus the patient had received a very high dose of remifentanyl that was probably the cause of the haemodynamic disturbances. The incident was an error in equipment use, facilitated by hurry, lack of checking of the equipment prior to its use, and the complex and unclear design of the devices' screens. After analysis of this incident, all TCI pumps were reviewed, and all the programs for infrequently used drugs were deleted. Furthermore, 2 pumps were selected for exclusive use in the cardiac surgery theatre, one with propofol-only programming, and the other with remifentanyl-only programming, both clearly marked and situated in fixed places in that theatre.
mesh_terms: D018681:Anesthetics, General / Q000008:administration & dosage / Q000009:adverse effects*; D001021:Aortic Valve / Q000601:surgery; D062787:Drug Overdose; D004868:Equipment Failure; D019544:Equipment Failure Analysis; D019918:Heart Valve Prosthesis Implantation; D006801:Humans; D007022:Hypotension / Q000139:chemically induced*; D007260:Infusion Pumps / Q000009:adverse effects*; D007431:Intraoperative Complications / Q000139:chemically induced*; D008297:Male; D008508:Medication Errors; D010880:Piperidines / Q000008:administration & dosage / Q000009:adverse effects*; D015742:Propofol; D000077208:Remifentanil; D012308:Risk Management
chemical_list: D018681:Anesthetics, General; D010880:Piperidines; D000077208:Remifentanil; D015742:Propofol
keywords: Anaesthesia; Anestesia; Análisis de fallos de equipamiento; Bombas de infusión; Equipment failure analysis; Infusion pumps; Patient safety; Seguridad del paciente