pmc.ncbi.nlm.nih.gov
A not so rosy picture: accidental intravenous injection of rose-tinted pourable chlorhexidine solution
Ishigami et al.1 described a patient in whom 800 mg chlorhexidine gluconate (4 mL of 20% solution) was accidentally injected instead of a muscle relaxant. The patient developed acute respiratory distress syndrome (ARDS) despite plasma exchange therapy and subsequently required venoarterial extracorporeal membrane oxygenator (ECMO) support for recovery.
Johner et al.3 inadvertently injected chlorhexidine gluconate solution into radial artery catheter, resulting in necrosis of the thumb requiring surgical debridement and arthrodesis of the thumb phalanges.
. Kudo et al.4 identified accidental intravenous injection of 10 mL of 20% chlorhexidine gluconate in central line port postoperatively as the cause of death of a 58-years-old woman who underwent synovectomy of her left middle finger.