BEUDAMED
    FDA Adverse Event Injury Summary report: N

    LIDOCAINE HCL INJ.

    MDR report key: 766920 · Received September 12, 2006

    Report

    Report Number
    766920
    Event Type
    Injury
    Date Received
    September 12, 2006
    Date of Event
    August 30, 2006
    Report Date
    September 11, 2006
    Manufacturer
    HOSPIRA GLOBAL MEDICAL AFFAIRS
    Product Code
    FMF
    Adverse Event
    Yes
    Report Source
    User Facility report
    Reporter Location
    NC, US
    Reporter Occupation
    RISK MANAGER

    Narratives

    Description of Event or Problem · 1

    PT HAVING THYROID PROCEDURE; LIDOCAINE WAS BEING INJECTED IN THE ET TUBE FOR CONTROL OF POST-OP COUGHING AND TRACHEAL IRRITATION. THIS IS BEING DONE UNDER THE DRAPES SINCE THE PROCEDURE IS STILL IN PROGRESS. THE CAP TO THE LIDOCAINE IS REMOVED AND THE TUBE IS DISCONNECTED. THE TUBE WAS RECONNECTED, BUT IT WAS NOT KNOWN TO PRACTITIONER THAT THE CAP TO THE LIDOCAINE WAS IN THE ELBOW OF THE ANESTHESIA CIRCUIT. THE PRACTITIONER HAD THE ELBOW AND THE CAP IN HIS RIGHT HAND AT THE SAME TIME WHEN THE CAP WENT INTO THE ELBOW. ATTACHING THE ELBOW TO THE ET TUBE APPARENTLY PUSHED THE CAP IN FURTHER. THE CAP IS A PERFECT FIT, IT TOTALLY OCCLUDES THE ELBOW, BUT THE ELBOW CAN STILL BE RECONNECTED TO THE ENDOTRACHEAL TUBE. AN EMERGENCY TRACH WAS PERFORMED IMMEDIATELY. THE CAP WAS THEN DISCOVERED. WHEN THE CAP WAS FOUND TO BE THE REASON FOR THE INABILITY TO VENTILATE THE PATIENT, THE TUBE WAS REMOVED, SHE WAS INTUBATED ORALLY AND THE TRACHEA WAS REPAIRED.

    Devices

    Seq Brand Generic Product Code Manufacturer Model Lot UDI-DI
    1 LIDOCAINE HCL INJ. SYRINGE, PREFILLED, RUBBER CAP FMF HOSPIRA GLOBAL MEDICAL AFFAIRS * 40-261-EV
    2 ADULT ANESTHESIA BREATHING CIRCUIT CIRCUIT, BREATHING, ANESTHESIA, ELBOW ATTACHMENT CAI VITAL SIGNS, INC. * *

    Patients

    Seq Age Sex Outcome Treatment
    1 54 YR Hospitalization| R