This content has been reviewed for SALG by Dr Alistair Baxter and Dr Mark Barley on behalf of The Society for Intravenous Anaesthesia

A patient was transferred from [Hospital 1] to [Hospital 2] for an emergency interventional radiology procedure. The patient was intubated prior to transfer and sedated with a propofol infusion. They were received by anaesthetic consultant and ODP, transferred to an anaesthetic machine and moved to an interventional radiology table. Whilst monitoring was being transferred from transfer monitoring, it was noted that the transfer propofol infusion pump had been switched to a TCI pump by [Hospital 2] team. Asked to confirm what infusion rate of 1% propofol was running (was at 15ml/hr during transfer), it transpired that the patient had commenced propofol TCI and had been given an induction dose of propofol (rate of propofol being administered was 126ml/hr) - unclear amount but possibly would have been between roughly between ??60-100mg taking into account amount remaining in syringe and estimated amount used on transfer. Propofol infusion immediately stopped. No blood pressure reading as local intra-arterial blood pressure monitor was not set up yet at this stage. No palpable carotid/femoral pulse was felt. CPR commenced - brief (<1 min of CPR) until central pulse felt again, and then improved with metaraminol administration. Once IBP trace back, SBP 70 on metaraminol infusion 20ml/hr and with subsequent improvement.

Commentary

This case illustrates the need for clear handover of the concentrations and infusion rates of all drugs from a transfer team to the recipients.

It is also essential to ensure that infusions are initially maintained at the same rate (ml/hr) during transfer until all telemetry is transferred to the recipient’s monitoring system.

If transferring from manual Total Intravenous Anaesthesia (TIVA) in ml/hr to a Target Controlled Infusion (TCI), a low target should be set initially and titrated upwards.  This will avoid the risk of a “second bolus” causing hypotension.

Processed EEG monitoring is recommended in any patient receiving TIVA + neuromuscular blockade at all stages of the transfer process to ensure adequacy of anaesthetic dosing and to aid identification of EEG suppression from overdose, hypotension or raised ICP (amongst other causes).