Worst job in America

[Twiggidy]

Figured. Dig shouldn’t even be anywhere near an OR pyxis. Can’t think of any need for it.

This part. We literally do cardiac anesthesia at my place and we don’t have dig anywhere near our carts. Why it would be anyway accessible on an OB floor puzzles me

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[Twiggidy]

I was helping a junior resident set up a spinal for an elective csection. I luckily caught the resident drawing up digoxin instead of bupivicaine. The junior resident should be vigilant and double check every medication. At the same time , the vials look similar and not sure why it’s in ob Pyxis. After I left , I heard there was an incident where digoxin was inadvertently given in spinal. During fellowship , a resident almost gave the local infiltration lidocaine into the spinal. Attending noticed before any harm was done.

I’m sorry…this is not directed at you personally but how is this happening?!

First of all, based on safety reasons it’s conceivable to tell the department to pony up for the spinal kits that have the bupivacaine included. That eliminates so many chances of error. Second, as others have said, I have no idea why dig is anywhere near any of these ORs and OB suites. I’d ask pharmacy to have it removed

 

[anbuitachi]

Careful what you wish for.
We had a “collaborative model” a little south from us. One MD for the hospital and one MD for the surgery center. Firefighters. Pay was decent… 600ish. Crnas did OB solo at night and MD “signs off” the next morning. Last week a crna gave IT digoxin instead of bupi. Patient died. Super sad.
ALL savings with a collaborative model are now washed down the drain for years and years to come as this is going to be a big settlement- horrendous PR. You put your license on the line with these setups AND you put patients at risk. Do yourself a favor and walk away from these jobs (especially CRNA teaching jobs).
Not worth it for you or the patients you take care of.

i dont even know where to get dig these days

 

[Arch Guillotti]

What is dig even doing anywhere within reach? I have never even seen a vial of it.

 

[dabears505]

I googled dig vials and they look just like the bup 2 ml vials. Maybe they are next to each other cuz they are alphabetical and I can see how the error is made

 

[sethco]

One of the hospital were I do a low volume of cardiac. Heparin stocked in the same slot as Vasopressin, right next to the Digoxin glass vials 😂

 

[Airway]

This is the actual issue; it's 2022 and there is no conceivable role for digoxin in an operating room.

I agree it doesn't need to be in the anesthesia drawers, but I like digoxin in sepsis on occasion...

Edit sepsis afib

 

[nimbus]

Eye drops are standardized in terms of colors. It’s interesting to think how that is the one field that seems to have figured that out. Pharmacists routinely post pictures of easily confused bottles on the pharmacy subreddit, the vial problem is similar.

I’m an ER doc so not drawing and giving lots of medications have seen and heard of many med errors that could maybe be prevented this way. (Including an intrathecal dig case involving anesthesia at a hospital I work at. Sad that it seems to be not all that rare.)

One of the hospital were I do a low volume of cardiac. Heparin stocked in the same slot as Vasopressin, right next to the Digoxin glass vials 😂

We don’t stock different drugs in the same cubby but we are continuously switching vendors. Vials and caps are not standardized so what is not a lookalike one week can be a lookalike the following week.

 

[Gern Blansten]

If you follow the link to the case Nimbus posted, it says digoxin is stored in the back right corner of drawer seven in the omnicell while bupivacaine is stored in the back right corner of drawer five (or maybe vice versa). The guy gave a SAB that did not set up and decided to do a second spinal and reached in the back right corner of the wrong drawer. Because it looked exactly the same and seemed to be from the exact same location (but was really a different drawer), the guy did not read the label and made an assumption based falsely on “location” (even though he was two drawers off) and vial appearance. Tragic human error.

 

[deleted875186]

View attachment 364006

One of the hospital were I do a low volume of cardiac. Heparin stocked in the same slot as Vasopressin, right next to the Digoxin glass vials 😂

See stuff like this all the time in hospitals I have been in. Pharmacy should be more helpful and try and improve safety, instead it seems they just wing it and place a bunch of meds in drawers without thought to organization that makes sense for workflow.

 

[sevoflurane]

Hoo boy, is that what’s going on at that CCI practice? Barf

The irony too is that they think 600k is a lot of money for a job like that

Big barf. CCI is just another AMC that leverages 1:10 ratios... I am sure they will be out soon.
Hospital should have stuck with their MD only practice. That 600k isn't that great once you look at the ins and outs of that job.

 

[Dr. Rude]

See stuff like this all the time in hospitals I have been in. Pharmacy should be more helpful and try and improve safety, instead it seems they just wing it and place a bunch of meds in drawers without thought to organization that makes sense for workflow.

This is not on the pharmacy. I find their efforts to be “helpful” and improve safety to create an unnecessary amount of work. We had to fight to have succinylcholine readily acceptable (not specifically vended)

 

[BLADEMDA]

I was helping a junior resident set up a spinal for an elective csection. I luckily caught the resident drawing up digoxin instead of bupivicaine. The junior resident should be vigilant and double check every medication. At the same time , the vials look similar and not sure why it’s in ob Pyxis. After I left , I heard there was an incident where digoxin was inadvertently given in spinal. During fellowship , a resident almost gave the local infiltration lidocaine into the spinal. Attending noticed before any harm was done.

The error begins with the pharmacy tech. He/She places the wrong vial in the Pyxis under "bupivacaine." The CRNA, resident or provider goes to the pyxis and actually withdraws "bupivacaine" but receives Digoxin. The vials look similar so the provider uses that vial without verifying the drug. This is the key error: NEVER TRUST THE PHARMACY TECH. I found this is a common source of errors for vital medications we use. Once you get BURNED by the pharmacy tech you won't get burned again. But, will the patient die or be harmed before you learn from this common mistake?

NEVER ASSUME THE DRUG STOCKED BY THE PHARMACY TECH IS THE CORRECT DRUG whether that drug is in your drawer or in the pyxis.

 

[DocVapor]

The error begins with the pharmacy tech. He/She places the wrong vial in the Pyxis under "bupivacaine." The CRNA, resident or provider goes to the pyxis and actually withdraws "bupivacaine" but receives Digoxin. The vials look similar so the provider uses that vial without verifying the drug. This is the key error: NEVER TRUST THE PHARMACY TECH. I found this is a common source of errors for vital medications we use. Once you get BURNED by the pharmacy tech you won't get burned again. But, will the patient die or be harmed before you learn from this common mistake?

NEVER ASSUME THE DRUG STOCKED BY THE PHARMACY TECH IS THE CORRECT DRUG whether that drug is in your drawer or in the pyxis.

It's not just that. I almost got burned early in residency because a pyxis controlled substance count was short one when I opened the drawer. It was middle of the night so I counted it three times and logged it three times, typed a note into pyxis, and then took what I needed. The next day I'm getting a phone call from the pharmacist accusing me of diverting, and told me they had already escalated it to the hospital CEO and my program leadership.

Later that afternoon the pharmacy tech "found" the missing vial that they hadn't added to the drawer.

 

[coffeebythelake]

Wet tap them with a 17g Tuohy and let the CSF flow.

This is a great way to give the patient a subdural hemorrhage

 

[coffeebythelake]

It's not just that. I almost got burned early in residency because a pyxis controlled substance count was short one when I opened the drawer. It was middle of the night so I counted it three times and logged it three times, typed a note into pyxis, and then took what I needed. The next day I'm getting a phone call from the pharmacist accusing me of diverting, and told me they had already escalated it to the hospital CEO and my program leadership.

Later that afternoon the pharmacy tech "found" the missing vial that they hadn't added to the drawer.

The hospital leadership and pharmacist should be apologizing and groveling for your forgiveness. That sort of accusation is legally actionable.

 

[Urzuz]

This is a great way to give the patient a subdural hemorrhage

If I was careless enough to give a patient an intrathecal dose of a medication like digoxin, I would roll the dice on sticking a Tuohy in her back and quickly taking off a lot of CSF versus letting her nerves marinate in it!

 

[coffeebythelake]

If I was careless enough to give a patient an intrathecal dose of a medication like digoxin, I would roll the dice on sticking a Tuohy in her back and quickly taking off a lot of CSF versus letting her nerves marinate in it!

I have a feeling that they never recognized it and it was only discovered to be wrong medication well after the fact

 

[Urzuz]

I have a feeling that they never recognized it and it was only discovered to be wrong medication well after the fact

Probably, but at the point we are pontificating on the safety/efficacy of giving IT Digibind, I say screw it, put a Tuohy it and let her rip

 

[abolt18]

I have a feeling that they never recognized it and it was only discovered to be wrong medication well after the fact

You are correct. Reading the report, digoxin showed up on her blood tests during her workup. That led to them evaluating the Omni cell and identifying the count was off by 1 on the digoxin.

 

[MirrorTodd]

You are correct. Reading the report, digoxin showed up on her blood tests during her workup. That led to them evaluating the Omni cell and identifying the count was off by 1 on the digoxin.

Just begs the question (and believe me, the full blame for that patient's death lies with the CRNA) why the **** are so many hospitals stocking digoxin in the OB machines? That just shouldn't be anywhere except maaaayyyyyybe the cardiac OR's.

 

[MirrorTodd]

Sadly, on a positive note, I think I just found my next qi project for a lucky resident to do.

 

[coffeebythelake]

Just begs the question (and believe me, the full blame for that patient's death lies with the CRNA) why the **** are so many hospitals stocking digoxin in the OB machines? That just shouldn't be anywhere except maaaayyyyyybe the cardiac OR's.

There are a lot of mistakes we can save a patient from in anesthesia. A drug error of this magnitude isn't one of them

 

[Twiggidy]

View attachment 364006

One of the hospital were I do a low volume of cardiac. Heparin stocked in the same slot as Vasopressin, right next to the Digoxin glass vials 😂

I wonder how much those little 5k vials cost in comparison to the bigger 10k or even 30k vials

 

[Twiggidy]

If you follow the link to the case Nimbus posted, it says digoxin is stored in the back right corner of drawer seven in the omnicell while bupivacaine is stored in the back right corner of drawer five (or maybe vice versa). The guy gave a SAB that did not set up and decided to do a second spinal and reached in the back right corner of the wrong drawer. Because it looked exactly the same and seemed to be from the exact same location (but was really a different drawer), the guy did not read the label and made an assumption based falsely on “location” (even though he was two drawers off) and vial appearance. Tragic human error.

I believe someone on admin said you have to type in Dig or bupiv to remove it and he bypassed that function (something that shouldn’t be allowed)

 

[Twiggidy]

The error begins with the pharmacy tech. He/She places the wrong vial in the Pyxis under "bupivacaine." The CRNA, resident or provider goes to the pyxis and actually withdraws "bupivacaine" but receives Digoxin. The vials look similar so the provider uses that vial without verifying the drug. This is the key error: NEVER TRUST THE PHARMACY TECH. I found this is a common source of errors for vital medications we use. Once you get BURNED by the pharmacy tech you won't get burned again. But, will the patient die or be harmed before you learn from this common mistake?

NEVER ASSUME THE DRUG STOCKED BY THE PHARMACY TECH IS THE CORRECT DRUG whether that drug is in your drawer or in the pyxis.

All of this 1000%

 

[Twiggidy]

I have a feeling that they never recognized it and it was only discovered to be wrong medication well after the fact

The strange thing about that case is they did an entire C-section with IT digoxin and apparently it was adequate surgical anesthesia? I don’t remember reading anything about resorting to general after the second “injection”

So IT dig given because first block was poor. Did a section. Patient got to recovery and then seized. It’s a sad situation but I’d also like to be a fly on the wall for that case

 

[Gern Blansten]

I believe someone on admin said you have to type in Dig or bupiv to remove it and he bypassed that function (something that shouldn’t be allowed)

Omnicells that are put in each individual OR have drawers that are controlled and drawers that are not controlled. Meaning, if you are logged in, you just open a drawer and pull out what you want. Ideally, you are supposed to scan each med you pull out but that is not always done.
So, I picture it as him opening the drawer and reaching into the back right corner of it and grabbing a vial. I don’t know details but that is how omnicell is set up at my place. So I don’t think he had to bypass anything because that is how it works for the non controlled drugs.
I can’t say for sure that this was his set up. That’s just what I’ve seen.

 

[ucladoc2b]

Omnicells that are put in each individual OR have drawers that are controlled and drawers that are not controlled. Meaning, if you are logged in, you just open a drawer and pull out what you want. Ideally, you are supposed to scan each med you pull out but that is not always done.
So, I picture it as him opening the drawer and reaching into the back right corner of it and grabbing a vial. I don’t know details but that is how omnicell is set up at my place. So I don’t think he had to bypass anything because that is how it works for the non controlled drugs.
I can’t say for sure that this was his set up. That’s just what I’ve seen.

This is likely the scenario. And probably they store the vials next to each other.

Personally, my fear of drug errors is what caused me to draw up minimal drugs for cases. Just too easy to grab the wrong 3 cc syringe.

And completely true about the double checking the pharm tecs. We have a fridge with prefilled syringes for our pumps. I’ve seen the wrong drug in the wrong box too many times to count.

 

[nimbus]

The strange thing about that case is they did an entire C-section with IT digoxin and apparently it was adequate surgical anesthesia? I don’t remember reading anything about resorting to general after the second “injection”

So IT dig given because first block was poor. Did a section. Patient got to recovery and then seized. It’s a sad situation but I’d also like to be a fly on the wall for that case

“This preliminary study showed that intrathecal digoxin is capable of producing spinal anesthesia in rabbits. Intrathecal administration of 12.5 g digoxin in 0.2 mL seems to be a safe dose in rabbits. The reverse Trendelenburg position should be maintained for 30 min. Further investigation is needed to evaluate the potential applicability of digoxin for spinal anesthesia and regional nerve block.”

Intrathecal Administration of Digoxin in Rabbits : Anesthesia & Analgesia

An abstract is unavailable.

pdfs.journals.lww.com

 

[BLADEMDA]

This is likely the scenario. And probably they store the vials next to each other.

Personally, my fear of drug errors is what caused me to draw up minimal drugs for cases. Just too easy to grab the wrong 3 cc syringe.

And completely true about the double checking the pharm tecs. We have a fridge with prefilled syringes for our pumps. I’ve seen the wrong drug in the wrong box too many times to count.

There are case reports of the bar code being wrong. The drug is incorrect and they put on the wrong bar code too! You must still verify the drug yourself.
I have seen the wrong bar code on the wrong drug!!

 

[med2010]

Our Pyxis is now full of orange stickers on any drugs with an approaching expiration date. The nearing expiration date is printed on the orange sticker, which is large enough to fully cover the drug name and concentration, and doesn’t peel off cleanly. I’m not sure if it’s intended to make us use that vial vs another with a later date, or to alert the pharmacy tech to remove it past that date. Either way, it’s another example of someone creating extra work that has serious potential consequences and little upside.

 

[BLADEMDA]

Our Pyxis is now full of orange stickers on any drugs with an approaching expiration date. The nearing expiration date is printed on the orange sticker, which is large enough to fully cover the drug name and concentration, and doesn’t peel off cleanly. I’m not sure if it’s intended to make us use that vial vs another with a later date, or to alert the pharmacy tech to remove it past that date. Either way, it’s another example of someone creating extra work that has serious potential consequences and little upside.

This needs to be brought up in committee for discussion. Your Chief/Chair needs to get that sticker removed or placed so that drug can be clearly seen including the name, concentration and expiration date. Any sticker which BLOCKS you from reading those details yourself is a violation of guidelines, patient safety risk and huge malpractice risk to the hospital.

 

[Gern Blansten]

This needs to be brought up in committee for discussion. Your Chief/Chair needs to get that sticker removed or placed so that drug can be clearly seen including the name, concentration and expiration date. Any sticker which BLOCKS you from reading those details yourself is a violation of guidelines, patient safety risk and huge malpractice risk to the hospital.

Should be easily solved by calling out the issue. Then it becomes one of this issues that will need to be revisited about every 2 years as personnel turn over and the new ones either don’t know or forget and lapse back into old habits.

 

[drmwvr]

View attachment 364006

One of the hospital were I do a low volume of cardiac. Heparin stocked in the same slot as Vasopressin, right next to the Digoxin glass vials 😂

Well, there's only 5 vials of the dig so that's not a big deal.... and is that heparin in the vasopressin slot or vasopressin in the heparin slot?....big diff...

 

[Twiggidy]

This needs to be brought up in committee for discussion. Your Chief/Chair needs to get that sticker removed or placed so that drug can be clearly seen including the name, concentration and expiration date. Any sticker which BLOCKS you from reading those details yourself is a violation of guidelines, patient safety risk and huge malpractice risk to the hospital.

Absolutely.

And a trick I learned from a colleague if you want to light a fire under admin's butt about an issue is to:
1. Put the issue in writing. That way your concern has been documented. Email whoever is in charge and save the email.
2. Use keywords like, " this issue is a safety issue and a danger to patient care" or something like that

When it's in writing and used with certain keywords they almost can't ignore it otherwise if there is a bad outcome you get a situation much like at John Muir with the peds case, ie all these people saying "don't do this. it's too dangerous" and the hospital proceeds anyway. It puts the ball in their court.

 

[Dr. Rude]

Absolutely.

And a trick I learned from a colleague if you want to light a fire under admin's butt about an issue is to:
1. Put the issue in writing. That way your concern has been documented. Email whoever is in charge and save the email.
2. Use keywords like, " this issue is a safety issue and a danger to patient care" or something like that

When it's in writing and used with certain keywords they almost can't ignore it otherwise if there is a bad outcome you get a situation much like at John Muir with the peds case, ie all these people saying "don't do this. it's too dangerous" and the hospital proceeds anyway. It puts the ball in their court.

I used to do stuff like that a lot. Openly CCing to my personal email as well. It works. But you will earn ill will and if you have any aspirations for a leadership role within the system you will quash them.

 

[Twiggidy]

I used to do stuff like that a lot. Openly CCing to my personal email as well. It works. But you will earn ill will and if you have any aspirations for a leadership role within the system you will quash them.

That’s true. I thought about that after I posted. Admin may not be in your corner with those moves and I guess it’s a risk reward decision at that point but I’ve also notice these same admins have no problem distancing themselves when the docs make mistakes. I guess just have to decide how important the issue really is

 

[NVO]

The error begins with the pharmacy tech. He/She places the wrong vial in the Pyxis under "bupivacaine." The CRNA, resident or provider goes to the pyxis and actually withdraws "bupivacaine" but receives Digoxin. The vials look similar so the provider uses that vial without verifying the drug. This is the key error: NEVER TRUST THE PHARMACY TECH. I found this is a common source of errors for vital medications we use. Once you get BURNED by the pharmacy tech you won't get burned again. But, will the patient die or be harmed before you learn from this common mistake?

NEVER ASSUME THE DRUG STOCKED BY THE PHARMACY TECH IS THE CORRECT DRUG whether that drug is in your drawer or in the pyxis.

pharm techs are messing up all the time. The most common is them putting Furosemide in the Dexamethasone bin. I've seen Oxytocin in the Ondansetron bin before too

 

[pgg]

I mean are they not buying the kits that has the 2ml bup already in the kit?

Several places I've worked in the last couple years have been plagued with spinal and epidural kits that normally have drugs in them, but are missing one or more because of supply chain issues. As in, the manufacturer normally includes all the drugs but if they can't get it, they just make the kits without. Same packaging, same label, just an empty spot where one of the drugs is supposed to be. So you're obligated to get it elsewhere.

Lately the common issue is epidural kits that don't have lido/epi test dose vials in them. L&D nurses have been scrounging up 1% and 2% lido with epi vials for us.

Better believe I triple scrutinize any vial a L&D nurse hands off to me ...

 

[deleted875186]

Several places I've worked in the last couple years have been plagued with spinal and epidural kits that normally have drugs in them, but are missing one or more because of supply chain issues. As in, the manufacturer normally includes all the drugs but if they can't get it, they just make the kits without. Same packaging, same label, just an empty spot where one of the drugs is supposed to be. So you're obligated to get it elsewhere.

Lately the common issue is epidural kits that don't have lido/epi test dose vials in them. L&D nurses have been scrounging up 1% and 2% lido with epi vials for us.

Better believe I triple scrutinize any vial a L&D nurse hands off to me ...

Absolutely …. An epidural or intrathecal medicine needs to be double and triple checked. I force myself to do it with spinal meds even included in the kit, and force myself to read the epidural bag.

 

[kb1900]

Several places I've worked in the last couple years have been plagued with spinal and epidural kits that normally have drugs in them, but are missing one or more because of supply chain issues. As in, the manufacturer normally includes all the drugs but if they can't get it, they just make the kits without. Same packaging, same label, just an empty spot where one of the drugs is supposed to be. So you're obligated to get it elsewhere.

Lately the common issue is epidural kits that don't have lido/epi test dose vials in them. L&D nurses have been scrounging up 1% and 2% lido with epi vials for us.

Better believe I triple scrutinize any vial a L&D nurse hands off to me ...

We’re sterilly making my own test doses at the start of OB calls. No lido w Epi for a couple months now. I think it’s a huge safety issue but when I voiced it I got back the ole “back in my day”

I think it’s dumb that a sleep deprived resident is batch making neuraxial medications but what I do I know.

 

[ranvier]

The error begins with the pharmacy tech. He/She places the wrong vial in the Pyxis under "bupivacaine." The CRNA, resident or provider goes to the pyxis and actually withdraws "bupivacaine" but receives Digoxin. The vials look similar so the provider uses that vial without verifying the drug. This is the key error: NEVER TRUST THE PHARMACY TECH. I found this is a common source of errors for vital medications we use. Once you get BURNED by the pharmacy tech you won't get burned again. But, will the patient die or be harmed before you learn from this common mistake?

NEVER ASSUME THE DRUG STOCKED BY THE PHARMACY TECH IS THE CORRECT DRUG whether that drug is in your drawer or in the pyxis.

Hey is this the same pharmacy tech that somehow wants to log me out to restock the Pyxis when we are unclamping the aortic cross clamp or carotid shunt?

 

[kidthor]

Hey is this the same pharmacy tech that somehow wants to log me out to restock the Pyxis when we are unclamping the aortic cross clamp or carotid shunt?

We must have the same pharmacy tech!!!

 

[DirtDocMD]

We must have the same pharmacy tech!!!

Mine, too!! They only come in the room when I’m pulling drugs for a quick turnover case, or coming off pump on a CABG.

 

[deleted875186]

We’re sterilly making my own test doses at the start of OB calls. No lido w Epi for a couple months now. I think it’s a huge safety issue but when I voiced it I got back the ole “back in my day”

I think it’s dumb that a sleep deprived resident is batch making neuraxial medications but what I do I know.

This is truely insane. Simply draw up some lidocaine or bupivacaine without epi for a test dose, and give a small dose, if no spinal block then incrementally give the epidural bolus. I have never seen a positive intravascular test dose before.

I don’t know of any guideline from the ASA that says you have to use a test dose? Anyone else aware of anything like this?

 

[nimbus]

We’re sterilly making my own test doses at the start of OB calls. No lido w Epi for a couple months now. I think it’s a huge safety issue but when I voiced it I got back the ole “back in my day”

I think it’s dumb that a sleep deprived resident is batch making neuraxial medications but what I do I know.

We have lidocaine with epi. If your pharmacy says they can’t get it, they’re not trying hard enough and are unwilling to obtain it through alternate suppliers (which would cost more). When our pharmacy pulls the same nonsense and tell us they cannot get a drug, we ask our partners at other hospitals if they have it. They always do and we ask our pharmacy to get it.

Our pharmacy is currently telling us that labetolol is in very short supply and trying to restrict its use. I recently did some fill in work for an anesthesiologist on medical leave at another hospital within the same health system. That hospital has no labetolol shortage.

 

[Gern Blansten]

I often see it within our own hospital system in the same city. One site goes on lockdown and told no more dilaudid, for example. You go to another site miles away and ask them how they are dealing with the dilaudid shortage and they say, “what dilaudid shortage?” They’re using it as normal with no restrictions.

 

[Ashers]

This is truely insane. Simply draw up some lidocaine or bupivacaine without epi for a test dose, and give a small dose, if no spinal block then incrementally give the epidural bolus. I have never seen a positive intravascular test dose before.

I don’t know of any guideline from the ASA that says you have to use a test dose? Anyone else aware of anything like this?

I saw a positive intravascular test dose once on my first OB rotation as a CA1. I placed the epidural, it worked, negative test dose. A few hours later it stopped working. So my attending and I came back to troubleshoot it. I did another test dose, aspirated, nothing, but when I injected, her HR shot up and she got the metallic taste. I haven't seen it since that's been over 10 years ago.

Oh and I heard of TXA being given in a spinal. I don't know the outcome. Not my case, but with an AA and right before I started working at the former job. The AA was gone before I got there. Also mixed up phenylephrine 10mg and zofran.

 

[Beeftenderloin]

This is truely insane. Simply draw up some lidocaine or bupivacaine without epi for a test dose, and give a small dose, if no spinal block then incrementally give the epidural bolus. I have never seen a positive intravascular test dose before.

I don’t know of any guideline from the ASA that says you have to use a test dose? Anyone else aware of anything like this?

They can definitely happen.

I’ve had an intravascular catheter with a positive test dose twice personally. And that’s having placed around 500 or fewer epidurals in my life. Robust tachycardic response shortly after injection.

Had a former co-resident take over OB once. Got called to assess a catheter placed just a little before shift change. Patient had never really got comfortable. First thing they did was draw back on the catheter and got frank blood.