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A 55-year-old woman who'd just returned from coronary bypass surgery was receiving a slow infusion of I.V. dopamine to increase cardiac output. The drug was being infused through the proximal port of the pulmonary artery (PA) catheter because all other I.V. lines were being used.
When the nurse wanted to measure the patient's cardiac output, she disconnected the dopamine line from the proximal port, then injected the sterile solution into the lumen.
Suddenly, the patient's blood pressure skyrocketed. The nurse immediately realized what had happened. The rapid injection of the sterile solution had forced the dopamine remaining in the lumen into the patient's heart, elevating her blood pressure.
The nurse called the patient's doctor, who ordered the dopamine infusion discontinued. Fortunately, the bypass graft was not damaged by the rapid increase in pressure.
The lesson from this error is clear. Don't use the proximal port of a PA catheter to infuse drugs. As much as 1 m1 of a drug could remain in the proximal lumen when you disconnect the tubing to measure cardiac output. Since this measurement requires a fast, forceful injection of up to 10 m1 of solution, the drug in the lumen will be rapidly injected into the patient's heart. This can seriously injure him, especially when such potent drugs as dopamine, epinephrine, or nitroprusside are being infused.
In fact, infusing drugs directly into the heart through a central line is controversial. So reserve the proximal port of the PA catheter for its intended use: infusing I.V. fluids and monitoring central venous pressure. Whenever possible, infuse drugs through a peripheral vein.