TY - JOUR
T1 - Hypertensive Crisis During Norepinephrine Syringe Exchange
T2 - A Case Report
AU - Snijder, Roland A
AU - Knape, Johannes T A
AU - Egberts, Toine C G
AU - Timmerman, Annemoon M D E
N1 - Copyright:
This record is sourced from MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine
PY - 2017/4
Y1 - 2017/4
N2 - A 67-year critically ill patient suffered from a hypertensive crisis (200 mm Hg) because of a norepinephrine overdose. The overdose occurred when the clinician exchanged an almost-empty syringe and the syringe pump repeatedly reported an error. We hypothesized that an object between the plunger and the syringe driver may have caused the exertion of too much force on the syringe. Testing this hypothesis in vitro showed significant peak dosing errors (up to +572%) but moderate overdose (0.07 mL, +225%) if a clamp was used on the intravenous infusion line and a large overdose (0.8 mL, +2700%) if no clamp was used. Clamping and awareness are advised.
AB - A 67-year critically ill patient suffered from a hypertensive crisis (200 mm Hg) because of a norepinephrine overdose. The overdose occurred when the clinician exchanged an almost-empty syringe and the syringe pump repeatedly reported an error. We hypothesized that an object between the plunger and the syringe driver may have caused the exertion of too much force on the syringe. Testing this hypothesis in vitro showed significant peak dosing errors (up to +572%) but moderate overdose (0.07 mL, +225%) if a clamp was used on the intravenous infusion line and a large overdose (0.8 mL, +2700%) if no clamp was used. Clamping and awareness are advised.
UR - http://www.scopus.com/inward/record.url?scp=85021308589&partnerID=8YFLogxK
U2 - 10.1213/XAA.0000000000000458
DO - 10.1213/XAA.0000000000000458
M3 - Article
C2 - 27898549
SN - 2050-0904
VL - 8
SP - 178
EP - 181
JO - Clinical case reports
JF - Clinical case reports
IS - 7
ER -