Article: Unintentional Neuromuscular Blocking Agent Injection During an Axillary Brachial Plexus Nerve Block

Objective: We describe the consequences of an unintentional injection of atracurium instead of ropivacaine during an axillary brachial plexus nerve block.

Case Report: A 79-year-old woman was scheduled for wrist fracture repair. An axillary brachial plexus block was performed by use of a nerve stimulator. Twenty milliliters of 0.5% ropivacaine with 1:200,000 epincphrine was injected on the radial and then on the median nerves. Two minutes later, the patient became dyspneic and was unable to elevate her head from the pillow. A check of the syringes revealed that one contained 50 mg of atracurium instead of 0.5% ropivacaine. After IV propofol was administered, the trachea was intubated and ...

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