Antibiotic or induction agent? Another problem from a possible solution

Abstract

We read with interest the correspondence regarding the risks of antibiotic prophylaxis in caesarean section [1]. In our unit, after a single incident involving the administration of thiopental instead of co-amoxiclav to a mother following delivery under spinal anaesthesia, and in consultation with our pharmacy, we decided to introduce pre-filled thiopental syringes. These are prepared in our pharmacy department and stored in specially labelled packets for use within seven days of preparation, with stocks regularly replenished by the hospitals’ pharmacists. Thiopental powder ampoules remain available for anaesthetic staff to use, according to personal preference. Since the introduction of pre-filled thiopental syringes, however, we have had two incidents of failed induction of anaesthesia in category-1 caesarean section. The second incident occurred in spite of our reducing the shelf-life of the thiopental syringes to just four days. On each occasion, the problem was quickly recognised and propofol was given before neuromuscular blockade. Indeed, several anaesthetists have now changed their practice, routinely using propofol instead of thiopental when inducing general anaesthesia for caesarean section. Contrary to recent guidance [2], we continue to administer antibiotic prophylaxis just after delivery, as it remains hospital policy to use co-amoxiclav, which is not recommended for use before delivery of the baby. This is not routinely prepared until the baby has been delivered safely, and it is counter-checked by the anaesthetic assistant before injection. We agree that human error is the real problem here, and would also welcome any further suggestions on how to deal with this problem. Fortunately, drug errors in anaesthesia are rare in comparison with ward-based care [3], but we can always do better.