依托咪酯和罗库溴铵误入脑室的病例报道

我们报道一例在重症监护病房（ICU）内，进行快速序贯诱导气管内插管时，依托咪酯和罗库溴铵误通过脑室引流管注入脑室的病例。诱导后患者意识迅速消失、无呼吸、声带外展、插管条件良好。在诱导和插管期间，该患者的血流动力学保持平稳。护士缺乏经验和系统差错是这起用药错误的原因。本文将对系统的管理、临床治疗、风险因素以及预防措施进行讨论。

We report the unintentional intracerebroventricular administration of etomidate and rocuronium tnrougn a ventriculostomy catheter in the intensive care trait 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 intubafion. 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.