Frewin D B, Cooper D J
Med J Aust. 1986 Apr 28;144(9):481-2. doi: 10.5694/j.1326-5377.1986.tb101056.x.
Eight patients who inadvertently received theophylline by mouth and aminophylline by the intravenous route together were reviewed by the Clinical Pharmacology Service of the Royal Adelaide Hospital because their serum theophylline levels were in excess of the stated therapeutic range. Six of these patients were severely compromised by their high theophylline level, and two of them, who had advanced obstructive lung disease and respiratory failure, died shortly after the drug levels were detected. Oversights of this nature can arise during the early stages of a patient's hospital admission and when medical staff changes occur. All patients who receive aminophylline by the intravenous route must be kept under close surveillance to ensure that theophylline formulations are not given by mouth concurrently.
八名意外同时口服了茶碱并静脉注射了氨茶碱的患者，由皇家阿德莱德医院临床药理服务部门进行了评估，因为他们的血清茶碱水平超出了规定的治疗范围。其中六名患者因高茶碱水平而受到严重影响，其中两名患有晚期阻塞性肺病和呼吸衰竭的患者在检测到药物水平后不久死亡。这种性质的疏忽可能在患者入院初期以及医护人员变动时出现。所有接受静脉注射氨茶碱的患者都必须密切监测，以确保不同时口服茶碱制剂。
