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Anesth Analg 2008; 106:520-522
© 2008 International Anesthesia Research Society
doi: 10.1213/ane.0b013e3181606ae5
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PATIENT SAFETY

Unintentional Intracerebroventricular Administration of Etomidate and Rocuronium

Stephen Howell, MD, and Richard P. Driver, Jr, MD

From the Department of Anesthesiology, West Virginia University School of Medicine, 3618 Robert C. Byrd Health Science Center, West Virginia.

Address correspondence and reprint requests to Stephen Howell, MD, Department of Anesthesiology, West Virginia University School of Medicine, 3618 Robert C. Byrd Health Science Center, P.O. Box 9134, Morgantown, WV 26506-9134. Address e-mail to howells2{at}rcbhsc.wvu.edu.

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.




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G. A. Mashour
Etomidate, Nitric Oxide, and Cerebral Vasospasm
Anesth. Analg., July 1, 2008; 107(1): 343 - 343.
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Home page
 Anesth. Analg.Home page
S. M. Howell and R. P. Driver
Etomidate, Nitric Oxide, and Cerebral Vasospasm
Anesth. Analg., July 1, 2008; 107(1): 343 - 344.
[Full Text] [PDF]


Lippincott, Williams & Wilkins Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins and Stanford University Libraries' HighWire Press®. Copyright 2008 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999 HighWire Press
Copyright © 2008 by the International Anesthesia Research Society.