Unusual Complication and Potential Safety Hazard from Simply Drawing up a Medication in the Operating Room

Abstract

To the Editor Many anesthetic medications are provided in glass vials with a rubber seal at the top, anchored to the glass vial by a metal band and protected by a plastic cap. To facilitate transfer of liquid medication from a glass vial into a syringe, it is common practice to pressurize the vial by first injecting air1 allowing for brisk filling of the syringe to the desired volume with minimal aspiration effort. We report a potentially hazardous complication of this technique after injecting 5 mL air into a 10 mL vial of rocuronium bromide (GeneraMedix Inc, manufactured by Gland Pharma Ltd, Hyderabad, India). On injection, there was a loud pop and the bottom of the vial exploded off the vial (Fig. 1), scattering glass fragments across the room. Fortunately, this incident occurred with the clinician turned away from the patient and operating room personnel. Practitioners should be aware of this rare complication and exercise caution when pressurizing glass vials. To systematically address this safety issue for the involved clinician, patients, and coworkers, preparing medications from vials should routinely occur turned away from any personnel, never at the practitioner’s eye level and with protective eyewear in place.Figure 1: A vial of rocuronium bromide before and after the described incident.David Moss, MD Roman Schumann, MD Department of Anesthesiology Tufts Medical Center, Boston, Massachusetts [email protected]