Consequences of human error in TCI pump programming

Docking, R., Staber, M. and Prinzlin, J. (2009) Consequences of human error in TCI pump programming. European Journal of Anaesthesiology, 26(45), 17AP1-17AP2.

Abstract

<p><b>Background and goal of study</b>: New open target controlled infusion pumps (TCI) allow the infusion of Remifentanil or Propofol without tagged syringes. Both drugs display different pharmacokinetics. Is there a potential for patient harm if the operator chooses the wrong pharmacokinetic model for the intended drug?</p> <p><b>Materials and methods</b>: Two user errors were simulated with the TIVAtrainer software using two different patient profiles: a 40 year old, 80 kg male and a 90 year old, 60 kg female. Both received Propofol 1% infusions using the Marsh model and Remifentanil (50 mcg ml-1) infusions using the Minto model.</p> <p><b>Results and discussion</b>: Error 1: Programmed drug Propofol infused drug Remifentanil</p> <p>40 year old male: Propofol 6 g ml-1 for 3 min followed by 3 g ml-1 for 27 min</p> <p>90 year old female: Propofol 4 g ml-1 for 3 min followed by 1.5 g ml-1 for 27 min</p> <p>On starting the TCI pump bolus doses of Remifentanil of 540 mcg and 500 mcg were delivered with corresponding plasma levels of 33 ng ml-1 and 28 ng ml-1. In the maintenance phase steady states were not reached and plasma and effect site concentrations approximated 8 ng ml-1 in the male and 6 ng ml-1 in the female patient. Short washout curves occured at the end of the infusion.</p> <p>The large initial bolus doses are of major concern as they may lead to deleterious cardiovascular responses, particularly in the elderly population.</p> <p>Error 2: Programmed drug Remifentanil infused drug Propofol</p> <p>40 year old male: Remifentanil 6 ng ml-1 for 30 min</p> <p>90 year old female: Remifentanil 5 ng ml-1 for 30 min</p> <p>Initial boluses of Propofol 41 mg and 34 mg were delivered at the beginning of the infusion. Peak plasma levels of 1.6 g ml-1 and 1.3 g ml-1 were reached after 30 minutes without achieving steady state. The wash-out time was prolonged. These settings may be sufficient to induce anaesthesia depending on additional drugs used and the pharmaco-dynamic response. However, lower than expected plasma levels may lead to intraoperative awareness, particularly in younger patients.</p> <p><b>Conclusion(s)</b>: Errors in programming multi-drug open TCI pumps may have clinically significant consequences ranging from cardiovascular collapse to risk of awareness during anaesthesia. Patient safety could be improved by introducing smart pumps with automatic drug recognition.</p>

• Item Type: Articles
• Keywords: Propofol, TCI, human error
• Status: Published
• Refereed: Yes
• Glasgow Author(s) Enlighten ID: Docking, Dr Robert
• Authors: Docking, R., Staber, M., and Prinzlin, J.
• Subjects: R Medicine > RD Surgery
• College/School: College of Medical Veterinary and Life Sciences > School of Medicine, Dentistry & Nursing > Clinical Specialities
• Journal Name: European Journal of Anaesthesiology
• ISSN: 0265-0215