![]() In this case, the 100 mL bag of milrinone completely infused in a very short time, leading the anesthesia resident to realize that an error had been made. If the pump was programmed with an erroneously low milrinone concentration of 200 mcg in 100 mL, the drug would infuse at a rate of 600 mL per hour. Hypothetically, for an 80 kg patient, the infusion rate to deliver a dose of 0.25 mcg/kg/minute would be 6 mL per hour, using a 20 mg/100 mL milrinone infusion bag. ![]() Hospira premixed milrinone lactate injection label contributed to a pump programming error because of the emphasis on 200 mcg per mL, not 20 mg/100 mL. Thus, the resident mistakenly thought the bag contained a total of 200 mcg/100 mL. The total amount per total volume (20 mg/100 mL), which should be the most prominent concentration expression following the drug name, is instead listed on the label in smaller print above the blue background. The per mL concentration, 200 mcg (0.2 mg)/mL, is the most prominent expression of the drug concentration, listed in large text right below the drug name at the center of a blue background on the label ( Figure 1). During investigation of the event, the resident felt as though the label on the Hospira premixed bag of milrinone also contributed to the error. Since the resident did not use milrinone frequently, he was unfamiliar with the Hospira packaging of the premixed infusion. As an aside, for this pump vendor, hard stops transitioned to soft stops in “anesthesia mode,” thereby allowing overrides of established dosing/concentration limits, even catastrophic limits. Since the pump did not alert him to the erroneously low concentration entry, the resident initiated the infusion. Prior to this incident, the resident was not aware of this function. However, if the resident had used the “All Drugs” option available in “anesthesia mode,” he would have been able to access a milrinone infusion entry, which included preestablished low and high concentration limits. Thus, he entered the drug concentration and dose manually. The resident was using the pump in “anesthesia mode.” Milrinone was not listed in the anesthesia drug library because it was rarely used. ![]() He then programmed the infusion pump to deliver the intended dose-rate of 0.25 mcg/kg/minute. He subsequently entered an incorrect milrinone concentration of 200 mcg in 100 mL, when the infusion bag he was hanging contained 20 mg in 100 mL of 5% dextrose. The resident was unfamiliar with the smart infusion pump available for use in the operating room (OR). The typical dose range is between 0.1 to 0.75 mcg/kg/minute. Milrinone is used in patients with acute decompensated heart failure with reduced ejection fraction, as well as before and after cardiac surgery. Problem: An anesthesia resident wanted to start a milrinone infusion on a perioperative patient who required inotropic support. ![]()
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