RECALL AFTER TOTAL INTRAVENOUS ANESTHESIA DUE TO AN EQUIPMENT MISUSE

Purpose: To present a case of recall after total intravenous anaesthes ia (TIVA) with propofol-alfentanil infusions to point out an uncommon misuse of the Bard InfusOR syringe driver. Clinical features: A health y patient underwent diagnostic dilatation and curettage and laparoscop y for lysis of peritoneal adhesions, After induction, anaesthesia was maintained with propofol-alfentanil infusions using the Bard InfusOR s yringe drivers. Ten minutes into maintenance, the patient was moving. The flashing green light confirmed the delivery of the medication and the alarms were not activated. However, the latch of the movable lever in the propofol syringe driver was found to be improperly positioned at the top of the plunger and only a small amount of propofol had been delivered. Postoperatively, the patient could recall the abdomen bein g touched during laparoscopy. An explanation was given and the patient was satisfied. Conclusion: The Bard InfusOR syringe driver is not des igned to detect a malposition of the lever on the syringe plunger. The anaesthetist must ensure proper placement the lever and visual confir mation of medication delivery in order to prevent awareness due to thi s particular problem.