[Acute poisoning with phenytoin caused by an error in the administration of fosphenytoin (Prodilantin)].
Following surgery for a chronic subdural haematoma, a 74-year-old patient received fosphenytoin as prophylaxis for epilepsy. The patient received 10 times the prescribed dose. This error in the administration of fosphenytoine was facilitated by a confusing labeling of the product. The phenytoin blood level was 79 micrograms.mL-1. The main adverse effect was a coma requiring 5 days of mechanical ventilation. No adverse cardiovascular event was noted. The phenytoin blood levels returned toward the therapeutic range in 8 days. At discharge from the hospital 20 days after surgery, the patient did not have any sequela from the fosphenytoin intoxication.
Département d'anesthésie-réanimation, CHU Timone, 13385 Marseille, France.
M
M
Presutti
L
L
Pollet
J M
JM
Stordeur
N
N
Bruder
F
F
Gouin
D000368:Aged; D000927:Anticonvulsants / Q000627:therapeutic use*; D005260:Female; D006801:Humans; D008508:Medication Errors; D010672:Phenytoin / Q000031:analogs & derivatives / Q000097:blood* / Q000506:poisoning / Q000627:therapeutic use*
D000927:Anticonvulsants; D010672:Phenytoin; C043114:fosphenytoin