title: Unintentional intracerebroventricular administration of etomidate and rocuronium.
abstract: We report the unintentional intracerebroventricular administration of etomidate and rocuronium through a ventriculostomy catheter in the intensive care unit during a rapid sequence induction for endotracheal intubation. Rapid loss of consciousness, apnea, and vocal cord abduction occurred, creating excellent intubating conditions. The patient remained hemodynamically stable throughout induction and intubation. Inexperience of nursing personnel and systems errors were factors contributing to the drug error. The management, clinical course, predisposing factors, and strategies for prevention will be discussed.
authors.affiliation: Department of Anesthesiology, West Virginia University School of Medicine, 3618 Robert C. Byrd Health Science Center, P.O. Box 9134, Morgantown, WV 26506-9134, USA. howells2@rcbhsc.wvu.edu
authors.forename: Stephen
authors.initials: S
authors.lastname: Howell
authors.forename: Richard P
authors.initials: RP
authors.lastname: Driver
mesh_terms: D000732:Androstanols / Q000008:administration & dosage* / Q000009:adverse effects; D005045:Etomidate / Q000008:administration & dosage* / Q000009:adverse effects; D017809:Fatal Outcome; D006801:Humans; D007276:Injections, Intraventricular; D008297:Male; D008508:Medication Errors / Q000009:adverse effects* / Q000517:prevention & control; D008875:Middle Aged; D000077123:Rocuronium
chemical_list: D000732:Androstanols; D000077123:Rocuronium; D005045:Etomidate