DEVICE SAFETY: Power injectors put I.V. lines under pressure

November 2004 
Volume 34  Number 11
Pages 29 - 29
  PDF Version Available!


  • What went wrong?

  • Preventing problems


    DURING A COMPUTED tomography (CT) scan, a power injector was used to administer contrast media into a patient's I.V. access site. Contrast media suddenly sprayed out of the I.V. administration set connector and into her face and eyes. Although the patient was wearing glasses, she complained that her eyes were burning, so her eyes were rinsed with water for 15 minutes.

    After the I.V. tubing was replaced, her CT scan was completed without further mishap. Fortunately, a subsequent ophthalmic exam in the ED didn't show any eye or skin injury and the patient was reassured.

    What went wrong?

    In this particular situation, the I.V. tubing connector failed because it wasn't designed to withstand the pressures of contrast media injection using a power injector.

    Power injectors are used to inject radiopaque contrast media at controlled ...

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