A case of accidental hypotension caused by drug leakage through the rubber piston in a prefilled inovan injection 0.3% syringe.

摘要

The use of prefilled syringes is recommended as a strategy to minimize errors in intravenous drug administration during anesthesia and intensive care. Prefilled syringe formulations of potent cardiovascular drugs are available to provide rapid access for critically ill patients. The prefilled syringe that requires assembly is composed of two parts: A plastic syringe plunger and an airtight syringe barrel with a rubber piston at one end and the enclosed drug. The operator has to assemble the syringe by fitting the plunger to the piston at an appropriate position before fixing the syringe into the syringe pump. We encountered a rare case of accidental hypotension as a result of failed dopamine delivery caused by drug leakage from a Prefilled Inovan injection 0.3% syringe (marketed by Kyowa Hakko Kirin Co., Ltd., Tokyo, Japan; manufactured by Terumo Corp., Tokyo, Japan). This leakage was noticed approximately 4 h after the start of the syringe pump infusion and appeared to be caused by plunger/piston misassembly. We report this case briefly to draw special attention to hazardous misassembly that may occur when using a prefilled syringe requiring assembly.