Saudi Journal of Anaesthesia

LETTERS TO EDITOR
Year
: 2020  |  Volume : 14  |  Issue : 3  |  Page : 410--411

Comment on the published article: Accidental injection of succinylcholine into epidural space as a test dose


Sohan L Solanki, Raghu S Thota 
 Department of Anesthesiology, Critical Care and Pain, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India

Correspondence Address:
Dr. Sohan L Solanki
Department of Anesthesiology, Critical Care and Pain, Tata Memorial Centre, Dr E Borges Road, Parel, Mumbai - 400 012, Maharashtra
India




How to cite this article:
Solanki SL, Thota RS. Comment on the published article: Accidental injection of succinylcholine into epidural space as a test dose.Saudi J Anaesth 2020;14:410-411


How to cite this URL:
Solanki SL, Thota RS. Comment on the published article: Accidental injection of succinylcholine into epidural space as a test dose. Saudi J Anaesth [serial online] 2020 [cited 2022 Jan 26 ];14:410-411
Available from: https://www.saudija.org/text.asp?2020/14/3/410/285434


Full Text



Dear Editor,

We read with interest the article “Accidental injection of succinylcholine into epidural space as a test dose” by Toleska et al.[1] The author has reported an accidental injection of succinylcholine as an epidural test dose. Fortunately, the patient did not have any neurological symptoms and signs in the postoperative period. Accidents do happen in medical practice and especially drug error is most common. We can and must avoid such accidents by proper labelling and double-checking as mentioned by the author. However, we wish to add certain points regarding the practice of epidural practice and test dose.

Epidural test dose standard practice around the world is either 3 mL of 1.5% lignocaine with 5 mcg of adrenaline per mL which is most commonly used or 3 mL of 0.25% or 0.5% bupivacaine with 5 mcg adrenaline per mL contrary from the 2 mL 0.5% bupivacaine without adrenaline used in this case.[2] Purpose of test dose is to rule out the intravascular placement of catheter which can be detected by adrenaline by an increase in the heart rate >10% from baseline in case of an intravascular placement and to rule out the subdural placement of catheter which can be detected by lignocaine or bupivacaine. The epidural test dose should always be prepared freshly because 1) it can assure strict aseptic environment, 2) adrenaline is unstable in lignocaine and preparing test dose well in advance can cause disintegration of the compound; and using commercial preparation of lignocaine with adrenaline (1:200000) does not serve the purpose of test dose since pH of the solution is highly acidic (3.3–5.5, average 4.5) as compared to pH of plain lignocaine solution (5.0–7.0) and it will be in the ionized form in acidic pH and local anesthetics penetrate the nerve membrane in the unionized form and block the action potential from inside the membrane in the ionized form,[3] and 3) it can avoid the drug error if it is prepared freshly just before giving the injection, of course with double-checking the ampoules.

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Conflicts of interest

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References

1Toleska M, Naumovski F, Dimitrovski A. Accidental injection of succinylcholine into epidural space as a test dose. Saudi J Anaesth 2020;14:238-40.
2Pennefather SH, Gilby S, Danecki A, Russell GN. The changing practice of thoracic epidural analgesia in the United Kingdom: 1997–2004. Anaesthesia 2006;61:363-9.
3Strichartz GR. The inhibition of sodium currents in myelinated nerve by quaternary derivatives of lidocaine. J Gen Physiol 1973;62:37-57.