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Epidural Syringe Swap

Epidural Syringe Swap

Epidural Syringe Swap

“plan was to slowly load the epidural prior to incision with an intended initial bolus of 10 mL of 0.25% bupivacaine with 1 mg of hydromorphone PF… [a] mistake was not noted until there was an attempt to load with another 5mL of 0.25% bupivacaine later in the case.”

Case Context    Provider Narrative    Contributing Factors    Lessons Learned

Case Context

Patient: adult male
Presenting diagnosis: kidney tumor
Planned procedure: open partial nephrectomy
Past medical history: hypertension
Anesthetic plan: general anesthesia with epidural for intraoperative and postoperative analgesia 


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