Unalarmed interruption of continuous drug infusion by Perfusor Space GC syringe pumps

摘要

We wish to report two cases of unalarmed syringe pump malfunction (Perfusor Space GC, B. Braun, Melsungen, Germany) that could have resulted in unintended intra-operative awareness.After uneventful testing of all devices, intravenous anaesthesia was induced in the first patient and subsequently maintained by propofol infusion at 6 mg.kg~(-1).h~(-1). Twenty-five minutes after induction, the patient's heart rate and blood pressure increased without surgical stimulus, so the depth of anaesthesia was increased by administering 0.3 mug.kg~(-1) sufentanil and repeated boluses of propofol via the syringe pump's bolus function (2 mg.kg~(-1) over 10 min), with the propofol flow rate increased from 6 to 12 mg.kg~(-1).h~(-1). Despite this, the patient moved his extremities. Suspecting a syringe pump dysfunction, a bolus of 1.4-mg.kg~(-1) propofol was administered manually, restoring clinical anaesthesia. The syringe pump was exchanged and surgery was accomplished without problems.