Pre‐filled syringes and safe total intravenous anaesthesia practice

I wish to congratulate the authors for the useful information contained within the recent Association of Anaesthetists guidelines for the safe practice of total intravenous anaesthesia (TIVA) 1. I was surprised, however, to see that these guidelines are not ‘state of the art’ for safe practice. In particular, they identified syringe labelling, accuracy of drug concentration and infection risks as important safety issues and also say ‘robust mechanisms should be in place to minimise the risk of drug error’ but then failed to mention the one strong systemic protective barrier to all of these, the use of pre-filled syringes. These were the strong systemic barriers referred to by NHS England in their Revised Never Events Policy and Framework in 2015 2; surely, in 2018, a key recommendation must be, therefore, that ‘when administering TIVA, pre-filled syringes should be used whenever possible’. Propofol is one of the anaesthetic drugs for which infections have been reported and have caused patient deaths 3. Compared with 6.3% of all medications drawn up in operating theatres being contaminated with micro-organisms 4 (particularly when multiple ampoules and diluents are used), syringes drawn up in a clean room are likely to remain uncontaminated. The 2018 Royal Pharmaceutical Society consultation to revise their Professional Guidance on the Safe and Secure Handling of Medicines highlighted a fundamental safety principle that ‘manipulation of medicines in clinical areas should be minimised’ and there therefore seems an incontrovertible argument for adopting the strong systemic barrier of pre-filled syringes. It is as if many of the TIVA enthusiasts have developed the technique in a very unbalanced way, concentrating on expensive high-tech syringe drivers and sophisticated pharmacokinetic models while illogically overlooking simple implementations to reduce total patient harm from the whole TIVA system. Inhalational anaesthesia long ago introduced the strong systemic barrier of keyed/funnel filling systems on vaporisers to stop the wrong agent being used. The opportunity was also missed to say we should be working towards only using syringe drivers that recognise the syringe contents by barcode or other technology. Apart from remifentanil, most of the other opioids used for TIVA have been available in 50-ml pre-filled syringes for many years 5 and, when caring for patients undergoing TIVA for over 20 years, I have always used pre-filled syringes of propofol. As acknowledged leaders in patient safety elsewhere, anaesthetists should be embarrassed at best on continuing to neglect established measures of injectable medication safety, when they are already much more widely used throughout the rest of medicine (heparin, vaccines, etc.). The WHO 3rd Global Patient Safety Challenge, which aims to reduce iatrogenic medication related harm by 50% in 5 years, calls upon all stakeholders to ensure that already known safety measures are fully implemented as a first step 6. All the worthy organisations involved therefore have a responsibility to amend this oversight of not recommending pre-filled syringes as soon as possible to stop them appearing out of date and to make this document truly guidelines for safe practice.