의료진의 실수로 인한 미다졸람의 근육 내 과다 투여 -증례보고-

Accidental Overdose of Intramuscular Midazolam -A Case Report-

  • 오세리 (원광대학교 치과대학 구강악안면외과학교실) ;
  • 김윤희 (원광대학교 치과대학 소아치과학교실)
  • O, Se-Ri (Department of Oral and Maxillofacial Surgery, School of Dentistry, Wonkwang University) ;
  • Kim, Yun-Hee (Department of Pediatric Dentistry, School of Dentistry, Wonkwang University)
  • 투고 : 2011.06.03
  • 심사 : 2011.06.17
  • 발행 : 2011.06.30

초록

We report two cases of accidental overdoses of intramuscular midazolam used for a conscious sedation. A 4-year-old boy with dental caries was scheduled for treatment under conscious sedation. The pedodontist prescribed midazolam ($dormicum^{(R)}$ 5 mg / 5 ml) 2 ml (2 mg) by verbal order to hygienist. The hygienist instead of the pedodontist wrote a prescription for midazolam ($dormicum^{(R)}$ 15 mg / 3 ml) 2 ml (10 mg). The inexperienced nurse gave an injection to his buttock as prescription. The child fell into a deep sedation. A 4-year-old boy with dental caries was scheduled for treatment under conscious sedation. The inexperienced pedodontist gave an injection to his buttock midazolam ($dormicum^{(R)}$ 15 mg / 3 ml) 3 ml (15 mg) instead of midazolam ($dormicum^{(R)}$ 5 mg / 5 ml) 3 ml (3 mg). The child fell into a deep sedation. Both cases had no complications, but the accidents happened as a result of the inexperienced dental staffs. The five times midazoalm instead of the intended doses was inadvertently given intramuscularly, fortunately caused no harm in our cases. However, the situations suggest that we should carefully check the dosage and review the correct procedures, even when using a drug that is considered to be familiar with most practitioners.

키워드

참고문헌

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