Enteral drugs given through a central venous catheter

A 74-year-old lady was given verapamil oral solution and a diclofenac dispersible tablet through her subclavian central venous catheter instead of her nasogastric tube five days after major head and neck surgery. The ensuing respiratory arrest resulting from profound ventilation-perfusion mismatch was made harder to manage by her potentially difficult airway. Information about the management of enteral drugs inadvertently given intravenously is sparse, and this sort of misrouting error is likely to be underreported. This case highlights the ease with which enteral preparations can be given by the wrong route.