Wednesday, 25 August 2010

Spinal chlorhexidine rumour is true - with Chinese whispers variations

Read the SMH story here.

Such an unfortunate story! And scary for all anaesthetists because I can see exactly how the mistake happened.  The story I heard though was a mother of 2 kids having a 3rd elective caesarean and spinal morphine in one pot and chlorhexidine in the other pot.  And then accidentally drew up chlorhexidine instead of spinal morphine.  And that the patient was paraplegic now.

The actual story is about a woman having a first baby having an epidural in labour, and chlorhexidine instead of saline was injected in the epidural space.  And she has patchy paraesthesias rather than full blown paraplegia.  Which is still bad but different from the story.

Lots of people ask me if that mistake can happen.  And I tell them the truth, it can happen and I can see how it happened.  Thank god it didn't happen to me, I feel sorry for the anaesthetist as well as the patient, I'm sure they're totally mortified by what happened.

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