Unintentional intracerebroventricular administration of etomidate and rocuronium.

Howell, Stephen; Driver, Richard P · Anesth Analg · 2008

case_report · Level V

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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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