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Respiratory arrest following inadvertent administration through a central venous catheter: case report A 74-year-old woman developed respiratory arrest after verapamil and diclofenac were inadvertently injected into her central venous line. The woman underwent right hemiglossectomy for squamous cell cancer of her tongue. A left subclavian central venous catheter and a nasogastric tube were inserted. On postoperative day 5, a critical care outreach team arrived to remove her central venous line. As they arrived, a ward nurse injected verapamil 60mg [Zolvera] oral solution into her central venous line instead of her nasogastric tube, followed by diclofenac 50mg [Voltarol] dispersible tablet, despite the outreach team’s protestation [therapeutic indications not stated]. She had a rapid decline in consciousness and a respiratory arrest. Her oxygen saturation was 77% with manual lung ventilation and 100% oxygen mask. She had vesicular breath sounds that were quieter at the bases. She had a BP of 110/80mm Hg, a HR of 90 beats/min and a Glasgow Coma Score of 10. Her oxygen saturation did not improve. She started to make respiratory efforts. The woman was transferred to an anaesthetic room. She was given sevoflurane in oxygen, followed by IV suxamethonium after a lung ventilation trial. An orotracheal tube was placed. During lung ventilation with FiO2 of 1, arterial blood gas analysis revealed the following: pH 7.36, PaO2 6.13 kPa, PaCo2 5.88 kPa, bicarbonate 23.7 mmol/L and base excess –0.6 mmol/L. Her hypoxia was assumed to be caused by ventilation-perfusion mismatch. A transthoracic ECG showed mild tricuspid regurgitation and an estimated pulmonary artery pressure of 28mm Hg. A CT scan with pulmonary angiography revealed large bilateral pleural effusions. About 2 hours after her collapse, her oxygen saturation increased rapidly to 99%. She was returned to the ICU. The next morning, 24 hours after her collapse, her trachea was extubated. Her pleural effusions were drained, but she developed chest sepsis with meticillin-resistant Staphylococcus aureus. She was reintubated and her lungs were ventilated. On postoperative day 11, she underwent a tracheostomy. She was slowly weaned off mechanical ventilation. Four weeks after her operation, she was transferred to ward care without a tracheostomy tube or central venous catheter. Finally, 8 weeks after surgery, she was discharged. Nicholson Roberts TC, et al. Enteral drugs given through a central venous catheter. 801081905 Anaesthesia 62: 624-626, No. 6, Jun 2007 - United Kingdom

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Reactions 28 Jul 2007 No. 1162