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Total intravenous anaesthesia | Signal

Reference number
1104 G
Issue date24 September 2009
TypeSignal

This ‘Signal’ is about the problems in use of equipment resulting in awareness under anaesthesia.

 

Extract from incident reported to the RLS:
“Syringe empty and refilled. Infusion recommended but 3 way tap left in `refilling’ position, therefore infusion not delivered to patient for 10 mins, TIVA pump did not alarm. Patient moved during surgery. Awareness reported post-operatively.”

 

Total intravenous anaesthesia (TIVA) has been used for some time in specialised surgery and is now more widely used across settings. It relies on continuous infusion of intravenous anaesthetic agents and, at times, intravenous fluids. Disruption of infusion or misconnections can result in anaesthetic awareness or errors in drug administration.

 

The National Reporting and Learning Service (NRLS) received a report of an incident of possible patient awareness through the specialty-specific anaesthetic reporting route. This was due to use of incomplete equipment without a one way anti-reflux valve in the connector.

 

Review of the wider Reporting and Learning System (RLS) showed 49 relevant incidents, including eight reports with possible anaesthetic awareness. Risk factors included problems with pumps, wrong labelling of syringes leading to incorrect drug strength, unfamiliarity of technique and problems with connectors on intravenous lines.

 

Although the Medicines and Healthcare products Regulatory Agency (MHRA) produces information on general use of intravenous pumps and equipment, there are no national guidelines for the administration of TIVA.

 

The new Safe Anaesthesia Liaison Group (core membership includes the Royal College of Anaesthetists (RCOA), the Association of Anaesthetists of Great Britain and Ireland and the NPSA) is producing guidance on the safe administration of TIVA. This gives clear actions for organisations (including purchasing equipment with safer labelling) and support for clinicians, including a diagram for correct placement of a one way valve.

 

 

We would like to hear from you – please contact us  with anonymised copies of local investigations or information about your initiatives to reduce risks in any of these areas. 

 

Contact the RCOA if you would like more information on TIVA guidance.

 

Signals are notifications of key risks emerging from review of serious incidents reported and shared by the NRLS.

 

Relevant to: Anaesthesia

 


Short Survey on the value and effectiveness of Signals

This is a pilot project. To assess the value and effectiveness of Signals, we would be grateful if you and your staff could take a few minutes to answer a  short survey. We would like to know if you have found Signals useful and how it could be developed further to suit your needs.