Accidental intracerebroventricular injection of anaesthetic drugs during induction of general anaesthesia.
A 51-year-old patient scheduled for surgery under general anaesthesia was accidentally given remifentanil 150 microg and propofol 1% 10 ml through an intracerebroventricular totally implantable access port placed in the right infraclavicular region, which was mistakenly thought to be an intravenous line. Severe pain in the head and neck caused the mistake to be discovered rapidly, and 20 ml of a mixture of cerebrospinal fluid and the anaesthetic drugs were aspirated from the implantable access port. The patient suffered no apparent adverse neurological sequelae.
Tiefenthaler
W
W
Department of Anaesthesia and Critical Care Medicine, Innsbruck Medical University, Innsbruck, Austria.
Tschupik
K
K
Hohlrieder
M
M
Eisner
W
W
Benzer
A
A
D000768:Anesthesia, General / Q000009:adverse effects; D018686:Anesthetics, Intravenous / Q000008:administration & dosage / Q000009:adverse effects*; D002552:Cerebral Ventricles; D006801:Humans; D015918:Infusion Pumps, Implantable; D008297:Male; D008508:Medication Errors; D008875:Middle Aged; D019547:Neck Pain / Q000209:etiology; D010880:Piperidines / Q000008:administration & dosage / Q000009:adverse effects*; D015742:Propofol / Q000008:administration & dosage / Q000009:adverse effects*; D000077208:Remifentanil
D018686:Anesthetics, Intravenous; D010880:Piperidines; D000077208:Remifentanil; D015742:Propofol