Outdated medical procedure behind catastrophic epidural injury

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THE medication practice that led to the catastrophic neurological injuries of a Sydney woman, Grace Wang, during an epidural was phased out of other hospitals more than a decade ago.

Ms Wang was poisoned during the birth of her first child in June at St George Hospital when an antiseptic skin preparation was accidentally injected into her spinal canal in place of an anaesthetic. The case has rocked NSW Health and shocked the public.

The two substances - both clear liquids - were placed in separate dishes on a sterile table in the delivery room, the Herald has learned, and were mixed up as a consequence of being unlabelled. Other hospitals insist drugs are drawn by the anaesthetist directly from their original vial or ampoule into a syringe.

... the practice of drawing medications from stainless steel dishes was routine a generation ago. ''It was identified as being an undesirable and unsafe practice.''

The antiseptic infused into Ms Wang's spine, chlorhexidine, has increasingly been used in the past five years in NSW because it mixes readily with alcohol, which accelerates drying and the epidural catheter can be inserted sooner.

The chlorhexidine wrongly injected into Ms Wang, who has suffered severe pain and can no longer walk, is understood to have been mixed with alcohol.

... The shift to chlorhexidine has been controversial, and a senior anaesthetist told the Herald betadine - the yellow iodine-based antiseptic which is easily distinguishable from clear epidural drugs - was probably safer ...

Melissa Maimann, Essential Birth Consulting 0400 418 448