Accidental intracerebroventricular injection of anaesthetic drugs during induction of general anaesthesia

Abstract

SummaryA 51-year-old patient scheduled for surgery under general anaesthesia was accidentally given remifentanil 150 lg 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. Subcutaneous implantation of totally implantable access ports (TIAPs) is now common in a number of clinical disciplines [1]. In patients with an implanted TIAP, general anaesthesia is usually induced via this infusion system to spare the patient additional venepuncture. We report the accidental injection of anaesthetic drugs through an intracerebroventricular TIAP during the attempted induction of general anaesthesia. Case reportA 51-year-old man suffering from a therapy-resistant pain syndrome with neuropathic pain in the right arm following trauma was brought to the operating theatre for implantation of an intrathecal infusion system. For scheduling reasons, the operating theatre and the anaesthetic team were changed at short notice. On arrival in the theatre, the patient was not fully alert and was receiving a morphine infusion through a TIAP implanted in his right infraclavicular region. A chest X-ray showed a TIAP (Port-A-Cath II, SIMS Deltec, St Paul, MN) implanted in the infraclavicular region with the catheter ascending towards the area of the right internal jugular vein (Fig. 1).A normal saline infusion was connected to the TIAP before induction of general anaesthesia, and standard monitoring was attached (ECG, pulse oximetry and automated non-invasive blood pressure). An infusion of remifentanil at a rate of 0.6 lg.kg )1 .min )1 was started by a trainee anaesthetist via the TIAP. Simultaneously, the patient was pre-oxygenated for 3 min, during which he appeared to become more sedated. Propofol 1% 10 ml were then injected. Seconds later, the patient complained of severe neck pain. The consultant anaesthetist was immediately called by the trainee anaesthetist; he quickly diagnosed the mishap. To minimise the possible toxic effect of the drugs, he attempted to withdraw the contaminated cerebrospinal fluid and aspirated approximately 20 ml of a mixture of propofol, remifentanil and cerebrospinal fluid. The patient's neck pain disappeared, but he remained sedated, so mask ventilation was continued, a peripheral venous line was inserted and the decision was made to induce general anaesthesia to secure the airway and prevent possible complications such as respiratory depression and convulsions. The planned intrathecal pump implantation was performed without complication, and the patient's trachea was extubated immediately after surgery. Postoperative neurological recovery was uneventful and cerebrospinal fluid examination on the next day revealed n...

Accidental Intraventricular Administration of Phenytoin Through an External Ventricular Drain: Case Report

“…[2][3][4] We could find no published report of accidental intrathecal injection of phenytoin in humans. The only article we found, by Martinez et al, 5 referred to the deliberate intraventricular infusion of phenytoin in pigs.…”

Cerebrospinal fluid diversion devices and shunting procedures: a narrative review for the anesthesiologist

“…Perioperative complications include the elevation of ICP or reduction in CPP during transport due to under drainage of CSF due to EVD clamped during an IHT and disconnection of EVD collecting system during patient movement, leading to contamination of the EVD system. Meningitis (range 0%-26%), 43 accidental injection of drugs [44][45][46][47][48] through an EVD mistaking it for an intravenous catheter, overdrainage of CSF with resultant "brain-sagging," and subdural hematoma formation are other notable complications.…”

Perioperative Management of Adult Patients With External Ventricular and Lumbar Drains: Guidelines From the Society for Neuroscience in Anesthesiology and Critical Care

“…8 To limit potential for Clostridium difficile diarrhea and antimicrobial-resistant organisms, as well as lack of efficacy, antibiotics are not routinely recommended for the duration of the EVD. 8 Although there are no guidelines or consensus statements regarding intraoperative periprocedural 67 Neural injury 68 Infection (0%-28% EVD, 0%-50% LD) 8,69-75 Malposition 2,76 Occlusion and malfunction [77][78][79] Overdrainage of CSF Subdural or epidural hematoma [80][81][82][83] Rebleeding from a ruptured cerebral aneurysm 84 Intracranial hypotension [85][86][87] Cerebellar tonsillar herniation 79,[88][89][90][91] Paradoxical herniation 92 Pneumocephalus 79,93 Iatrogenic vascular injury (arteriovenous fistula, cerebral pseudoaneurysm) 94 Fracture of catheters, 95 with retained fragment of catheter 96,97 Inadvertent injections of drugs into EVDs [98][99][100][101][102][103][104][105] Postdural puncture headache 106 CSF indicates cerebrospinal fluid; EVD, external ventricular drain; LD, lumbar drain. administration of antibiotics before LD placement for aortic and nonaortic surgery, this task force recommends following standards such as those used for EVD insertion and management.…”

“…This creates the opportunity for providers to inadvertently inject drugs into the ventricular system that are meant for intravenous use. There are many case reports and case series that describe accidental intrathecal injection of agents as varied as anesthetic drugs, 98,99 antibiotics, chemotherapeutic agents, or gadolinium contrast, frequently with devastating or fatal consequences. [102][103][104][105] Care should be taken to prevent this severe complication by carefully labeling EVD tubing and access ports, and using color-coded caps (please refer to educational document that accompanies this publication, Supplemental Digital Content 2, http://links.lww.com/JNA/A47).…”