'Intravenous' Cannulation: Always Assumed; Rarely Verified; Sometimes Dangerous - A Case Report

Abstract

We report a case of a baby boy who inadvertently received 4ml of propofol intra-arterially for sedation. The only warning sign was excessive crying followed by hyperemia and blanching of the limb. Management was immediate cessation of injection and follow up. While the child did not have permanent damage, we highlight the possible error of assuming the correct site of a pre-existing intravenous line and propose a mandatory confirmation of intravenous line placement when transferring care.