Just a little bit more food for thought - I saw this happen - did not happen
to me personally but it's something I realize that possibly could - I guess
this could have happened to anyone who was less than careful at the time.
There was this patient, young fit man in his 20's in for day endoscopy. The
operator gave him first 5 mg of midazolam, then 10mg, then a total of 20mg
or more (can't recall how much he was actually given) and could not
understand why your man was still awake and alert. Finally he fell asleep.
And remained groggy for the next 36 or so hours. The blood pressure cuff and
your man's arm, whatever way he had it must have caused the iv to tissue. He
got ALL the midaz into his subcutaneous tissues, where it sat there like a
depot which lasted ages.
Fortunately he remained stable and just required observation till the
sedation wore out. No real harm done ultimately but he had to be kept in.
Family were all alarmed etc. Quite a few ruffled feathers to smooth down. I
suppose this incident has really made me VERY paranoid about any iv cannula
I see, whether it's in or not....
Robert Spykerman
----- Original Message -----
From: "A S Lockey" <[log in to unmask]>
To: <[log in to unmask]>
Sent: Monday, October 15, 2001 7:22 PM
Subject: Re: Flumazenil, Sedation and Fits
> WARNING - ANECDOTAL EVIDENCE ALERT!
>
> Several years ago, whilst doing anaesthetics in a DGH south of Yorkshire
> (missionary work), an A&E SHO zonked a patient with midazolam for a
> dislocated shoulder then reversed him after relocation with flumazanil as
> she had been told that this was routine practice. As he was elderly and it
> was late evening, he was admitted for observation. He was placed on a
> nightingale orthopaedic ward in the 'bed of doom' at the end (usually
> reserved for ultra-fit or imminently croaking) and when his next lot of
obs
> were due, was found deceased from a respiratory arrest. It was decided
that
> he had re-sedated after the flumazanil had worn off with midazolam still
on
> board.
>
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