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Please help - anaesthetists

(29 Posts)
Tigress2014 Sun 22-Jan-17 16:59:44

Hello. I posted before about how many 6 day old baby had a general anaesthetic and didn't react well - he had apnoea, stopped breathing and was very hard to wake. I have just looked at the anaesthetic records and it says they gave 1mg (i.v.) dose of neostigmine and 200mcg (i.v.) dose of glycopyrrolate as a muscle relaxant reversal. I have checked on the web and I can't see how this can be right. My son weighed around 3.6kg at the time. Can anyone please help with this - I am going out of my mind with worry. Thanks.

BingoBingoBingoBango Sun 22-Jan-17 17:12:53

What can't be right? I'm a children's nurse and I don't know.

Have you spoken to the ward you were on or your consultant? Or PALS?

SandunesandRainclouds Sun 22-Jan-17 17:14:33

Is it the dosages you are querying or something else?

Tigress2014 Sun 22-Jan-17 17:15:32

The recommendations say 0.03 mg/kg to 0.07 mg/kg so 1mg would be huge overdose or am I interpreting this wrong?

BingoBingoBingoBango Sun 22-Jan-17 17:22:17

From what I can see at a quick glance the BNFC says 50mcg/kg. Where are you liking?

BingoBingoBingoBango Sun 22-Jan-17 17:22:24

Looking I mean.

Tigress2014 Sun 22-Jan-17 17:25:38

All the websites I looked at said the same:
www.drugs.com/dosage/neostigmine.html

Tigress2014 Sun 22-Jan-17 17:31:01

50mcg is the same as 0.05mcg

Tigress2014 Sun 22-Jan-17 17:41:09

Any anaesthetists? Please...

SandunesAndRainclouds Sun 22-Jan-17 17:49:26

You are interpreting it incorrectly.

Assuming the link you've provided is correct, then it says the maximum dose is of 0.7mg per kg up to a total dose of 5mg.

So - 0.7mg x 3.6(kg) = 2.52mg maximum dose for this weight. So no, 1mg wouldn't be an overdose.

*Disclaimer - I'm an ex-nurse who hasn't done drug calculations for ages and I am happy to be corrected!

Threepio Sun 22-Jan-17 17:59:19

Not an Anaesthetist, just a junior Dr on a Paediatric Surgical ward but the Children's BNF says Neostigmine is 300mcg per kg for Neonates. That would give a dose of 1.08mg so not an overdose as far as I can tell. I may very well be wrong and if you are worried you need to speak to your Consultant.

I know we often keep babies less than 12 weeks old in for observation after an anaesthetic, even after a small operation, as there is a huge amount of evidence that suggests they are more at risk of apnoeas and therefore close monitoring for about 24 hours/overnight.

Tigress2014 Sun 22-Jan-17 18:06:03

Firstly - thanks for answering me. I am in s real panic.

SandunesAndRainclouds - it is 0.07mg not 0.7mg. See below:
Usual Pediatric Dose for Reversal of Neuromuscular Blockade
Initial dose: 0.03 mg/kg to 0.07 mg/kg injected intravenously over a period of at least 1 minute
Maximum dose: 0.07 mg/kg or up to a total of 5 mg, whichever is less

Hence my concern that he had 10x the amount.

Threepio - that would be very reassuring but is that for reversal of muscle relaxants? Everywhere I look states it is between 0.03-0.07mg (30-70mcg)?

SandunesAndRainclouds Sun 22-Jan-17 18:11:39

My error, sorry. (Good job in an ex-nurse, right?!)

Have you taken this to PALS? I've been through the NHS formal complaint process and I was given the opportunity to discuss DD's care with senior doctors.

I believe the BNF over a website with no evidence of its accuracy.

Tigress2014 Sun 22-Jan-17 18:19:20

We are in the process of complaining to PALS but they have not been forthcoming or transparent.

There are different uses for neostigmine. Even the WHO website states:
"Dosage
Reversal of muscle relaxation
Children: 40 micrograms/kg i.v. after atropine sulfate (20 micrograms/kg i.v.) administered as above.
Titration of the required dose using a peripheral-nerve stimulator is advisable in small children and severely ill patients."

I am scared about the long term effects of this. She apparently gave him two doses as well.

Threepio Sun 22-Jan-17 18:28:26

Tigress, it's the only dose I could find on my phone app. Officially it's for Myasthenia gravis and can be given every 4 hours. I don't have access to a book at home I'm afraid! Side effects of an overdose do not include apnoeas...

I've just had a read of your other thread and it really sounds like you could do with a de-brief. You could ask for the Anaesthetist and Surgeon to be present to discuss their decisions with you.

Tigress2014 Sun 22-Jan-17 18:45:24

Thanks Threepio. It's different for myasthenia gravis unfortunately. We asked lots of questions in writing and the lead anaesthetist just came back with inaccuracies and untruths in the main. I understand that they close ranks in situations like this but when it is a baby involved it just isn't good enough. I think the next step is legal advice tbh.

Is there anyone who can shed light on the neostigmine dose? If it makes any sense she also gave 200mcg glycopyrrate with it which think is the right dose for 1mg neostigmine so would mean that that was 10x the correct amount as well...

Tigress2014 Sun 22-Jan-17 18:46:28

And I have just checked the dose of neostigmine and glycopyrrolate so I haven't raised that with PALS yet...

Threepio Sun 22-Jan-17 19:25:32

Sorry Tigres! Though if it's safe to give those kind if doses for Myasthenia there shouldn't be any long term effects from a one oft dose.

It could be that they did what I did and looked it up for the wrong condition. Or they could have started with the "correct" dose and titrated up when it wasn't enough, then just put the total dose given on the chart. Difficult to know without being there I am afraid!

We really shouldn't close ranks and I am always as honest as I can be. Unfortunately, it's easy to forget that you come at things from a very different angle with 5+ years of medical school and a few years working as a Dr behind you! And a reminder of that and patients asking questions is never a bad thing smile

I can't find anything that suggests either of these drugs have long term complications, all their side effects would end as the drug is cleared from your system.

I'm not really sure what else to suggest apart from a debrief. You could ask for a 2nd opinion and take the notes with you but I'm not sure it will give you the peace of mind you are looking for without someone who was there and can talk you through each decision made!

Tigress2014 Sun 22-Jan-17 19:49:12

Thanks Threepio. She gave another dose later on as well (within an hour) so we are actually talking 20x the recommended dose. My son didn't move for almost two days because of her error so I will be speaking to med negligence lawyers in the morning. Thanks for helping out x

BoobleMcB Sun 22-Jan-17 20:43:38

Does this help...

BoobleMcB Sun 22-Jan-17 20:47:21

That's from the BNFC by the way smile

BingoBingoBingoBango Sun 22-Jan-17 21:35:10

That's what I said earlier.

We follow the BNFC. Hospitals also have their own drug policies about various medicines.

Tigress2014 Sun 22-Jan-17 21:43:12

50mcg is 0.05mg x 3.6 = 0.18mg. He was given 1mg.

BoobleMcB Sun 22-Jan-17 21:52:26

I've no idea where they got it from. Like PP said, without being there nobody can say. I just thought I'd post the BNFC page

SandunesAndRainclouds Sun 22-Jan-17 22:04:00

I agree that no one can safely say why the dose was given without being there.

What are the long term side effects that are worrying you? From my limited reading, the only effects are while the drug is in the body and once it is gone, it is gone.

By all means persue this and find out what happened during / after surgery but please don't tie yourself up in knots by obsessively Googling and filling your mind with information that may, or may not, be useful. You'll make yourself ill. Please know that this comes with kindness and from someone who has done just that flowers

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