Trulzsch D V, Penmetsa A, Karim A, Evans D A
Department of Medicine, Wright State University School of Medicine, Dayton, Ohio.
South Med J. 1992 Dec;85(12):1255-6. doi: 10.1097/00007611-199212000-00025.
A 43-year-old man with dysphagia and a tendency to aspirate was found to have squamous cell carcinoma of the esophagus. Curative surgery was planned and preoperative computed tomography of the chest and abdomen was ordered. A ward nurse administered Gastrografin according to a "standing" order, 4 hours before the CT was to be done. The patient aspirated about 50 mL of Gastrografin, and went into cardiorespiratory arrest caused by pulmonary edema. He sustained severe brain damage and died. This is a first report of lethal aspiration of Gastrografin, given in preparation for CT. We advise alerting nurses who administer Gastrografin, especially to patients with dysphagia or impaired consciousness about the grave consequences that can result if the contrast agent is aspirated by the patient. We further advise that responsibility for using contrast agents in radiologic procedures be assumed by the radiologist and not by medical house staff.
一名43岁男性，有吞咽困难及误吸倾向，被诊断为食管鳞状细胞癌。计划进行根治性手术，并安排了术前胸部和腹部的计算机断层扫描。在CT检查前4小时，一名病房护士按照“常规”医嘱给患者服用了泛影葡胺。患者误吸了约50毫升泛影葡胺，随后因肺水肿导致心肺骤停。他遭受了严重的脑损伤并死亡。这是首例因准备CT检查而致死性误吸泛影葡胺的报告。我们建议提醒负责给予泛影葡胺的护士，尤其是对于吞咽困难或意识障碍的患者，告知他们如果患者误吸造影剂可能导致的严重后果。我们还建议在放射检查中使用造影剂的责任应由放射科医生承担，而不是住院医务人员。
