Injection intraveineuse accidentelle de chlorure de potassium : facteurs contributifs et obstacles à la réduction du risque

Errors linked to injectable potassium chloride (KCl) have been the cause of deaths which have occurred for many years. Following an accidental direct intravenous injection of KCl of no clinical consequence for the patient, we have analyzed the contributive factors, established an action plan to prevent this risk and finally assessed its impact. Among the causes leading to medication errors, we have identified those linked to the handling of the drugs by nurses, the team, the work conditions, the organization, the institutional context and finally to the drug itself. The risk reduction procedure involved a withdrawal of injectable KCI ampoules from wards, possible in 52% of the care units, a reorganization of storage for the others. The subsequent monitoring of floorstocks revealed that these measures were insufficient and that the risks prevailed due to the presence of KCI ampoules in drawers assigned to other ionic solutions. A study carried out among the medical and nursing personnel revealed that 61.2% of the doctors thought that the risk existed in their ward and 68% of the nurses considered themselves to be exposed to the risk of a medication error. The drug supply chain of our institution, as in numerous others, is not safe. Hospitals are not yet organized adequately to prevent the occurrence of such an error. The comparison with foreign organizations of drug dispensation allows us to think that the improvement and professionalization of the drug supply chain will both be assets in the prevention of such medication errors.     

Dissection de l''aorte ascendante au cours de la grossesse: césarienne et réparation chirurgicale de l''aorte simultanées

The authors report a case of an ascending aorta dissection, occurring at 35 weeks of pregnancy. Emergency Caesarean section, and surgical aortique dissection repair under cardio-pulrnonary bypass, were undertaken. The aetiology, diagnosis and anaesthetic management are discussed.     

Ajustement de la posologie de la vancomycine administrée en perfusion continue chez des patients de réanimation

Introduction

As the susceptibility of staphylococcal strains to glycopeptides rises, it is becoming necessary to increase vancomycin dosages.

Objective

To evaluate an administration protocol for vancomycin using continuous infusion with a loading dose of 30 mg/kg followed by 30 mg/kg per 24 h in intensive care patients presenting creatinine clearance (CLc) greater than 50.

Results

A total of 22 patients were included in the study. Serum vancomycin concentrations after 24 h (C24h) ranged from 25 to 30 mg/l in seven of 14 patients with CLc less than 120 ml/min (50 %), compared with three patients (21 %) with C24h greater than 35 mg/l and four patients (29 %) with C24h less than 25 mg/l. However, C24h was less than 20 mg/l for the eight patients with CLc greater or equal to 120 ml/min. Bacteriological data was available for eight of the 14 patients with CLc less than 120 ml/min, and in these eight patients, the C24h/MIC was greater or equal to 8; seven of these patients had an AUC/MIC greater or equal to 350.

Conclusion

Assay of serum vancomycin concentrations after 24 h of treatment is necessary to enable rapid adjustment of vancomycin concentration in order to improve therapeutic efficacy or avoid nephrotoxicity.