Unintentional i.v. injection of barium sulfate in a child

摘要: Purpose A case of barium sulfate injection into the superior vena cava during an upper gastrointestinal series (UGIS) in which patient’s central venous line (CVL) was mistaken for her gastrostomy tube is reported. Summary 17-month-old girl brought to fluoroscopy suite undergo a UGIS with contrast. Her medical history included premature birth and short-gut syndrome after bowel resection necrotizing enterocolitis gastroschisis. She had been treated multiple bouts sepsis currently receiving antibiotic therapy at home via CVL. admitted hospital replacement In hospital, patient developed diarrheal illness projectile vomiting, prompting UGIS. suite, approximately 3 mL injected CVL, misidentified as tube. The error recognized when first video fluoroscopic image revealed right atrium, 10 blood containing thick, chalky, whitish-pink suspension immediately aspirated from Peripheral access established, CVL removed. vomited three times rigors 30 minutes later. That evening, she fever, acetaminophen course broad-spectrum antibiotics. Subsequent radiographs chest failed show any residual barium, no respiratory distress developed. discharged stable condition four days later. Conclusion inadvertently received by i.v. through that