title: Misconnections in the Critically Ill: Injection of High-Dose Gadolinium into an External Ventricular Drain.
abstract: We report an unfortunate case of accidental administration of intrathecal gadolinium through an external ventricular drain in a postcraniotomy patient during magnetic resonance imaging of the brain. The incident occurred after the venous contrast line was connected mistakenly to the ventricular drainage catheter. The patient subsequently developed confusion, aphasia, and right facial droop with new computed tomography evidence of diffuse cerebral edema and stroke. Review of the magnetic resonance image revealed the inappropriate presence of subarachnoid gadolinium. Despite all interventions, the patient developed irreversible neurologic disability. We address the clinical sequelae, management strategies, and factors contributing to the catheter misconnection that led to this event.
authors.affiliation: From the *Department of Anesthesiology and Perioperative Medicine, †Neurosurgery, and ‡VA Greater Los Angeles Health Care System, UCLA Medical Center, Los Angeles, California.
authors.forename: Sumit
authors.initials: S
authors.lastname: Singh
authors.forename: Sepehr
authors.initials: S
authors.lastname: Rejai
authors.forename: Zarah
authors.initials: Z
authors.lastname: Antongiorgi
authors.forename: Nestor
authors.initials: N
authors.lastname: Gonzalez
authors.forename: Matthias
authors.initials: M
authors.lastname: Stelzner
mesh_terms: D001929:Brain Edema / Q000209:etiology*; D016638:Critical Illness; D004322:Drainage; D005682:Gadolinium / Q000008:administration & dosage* / Q000009:adverse effects*; D006801:Humans; D008279:Magnetic Resonance Imaging / Q000379:methods; D008297:Male; D008508:Medication Errors / Q000009:adverse effects*; D008875:Middle Aged; D020521:Stroke / Q000209:etiology*
chemical_list: D005682:Gadolinium