Abstract

PURPOSE:

A case of barium sulfate injection into the superior vena cava during an upper gastrointestinal series (UGIS) in which the patient's central venous line (CVL) was mistaken for her gastrostomy tube is reported.

SUMMARY:

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

CONCLUSION:

A 17-month-old girl inadvertently received barium sulfate by i.v. injection through a CVL that was mistaken for the patient's gastrostomy tube.