Unintentional Intravascular Injection of Penicillin

Abstract

TECHNIQUE designed to reduce the possibility of accidental entry into a blood vessel while giving an intramuscular injection of penicillin is being used at the venereal disease clinic of the central district of the Los Angeles Health Department. Many investigators have expressed the view that some severe reactions or sudden death following an intramuscular injection of penicillin may be caused by unintentional injection into a vessel rather than by anaphylaxis (1-18). experiments performed on cats to study the effect of deliberate intravenous injection of penicillin and, if possible, to determine the cause of any reaction that might occur, severe reactions and sometimes death followed (3). The median lethal dose of procaine penicillin given intravenously to cats is about 100,000 units per kg. of body weight. Necropsy findinigs in cats given this dosage suggested that pulmonary embolism played an important role in their reactions to deliberate intravenous injection. During these experiments, for comparison, 10 cats were given 51 intramuscular ininjections, each injection containing 300,000 units of penicillin. No untoward reactions were observed. light of these experimenits Bell and associates stated (3): is inferred that accidental intravenous injection of suspensions of procaine penicillin is the cause of some of the severe or fatal reactions in man. The results of these experiments suggest therefore that some fatalities reported in the literature (2-5) were caused by entry of some material into a vein rather than by anaphylaxis as previously believed. The same reasoning may apply to reports of nonfatal, severe, or mild reactions suffered by patients who had a history of uneventful penicillin injections. Reports of postmortem examination on persons who died after supposedly intramuscular injection reveal a variety of findings: cerebral edema (5, 10-12), edema of the lungs (2, 5, 11, 13), and purpura cerebri (10, 14,15). Inadvertent intravenous injection of other substances may cause reactions identical to those caused by penicillin. For example, Beerman (16) stated: A survey of the literature on fatalities due to bismuth in the treatment of syphilis reveals that intravenous injection is primarily responsible for sudden death and that the deaths are preceded by symptoms of colloidoclastic shock. Fortunately, however, adverse reactions to antibiotics are rare. According to Fasel (4), about 1 fatal accident may happen in 1 million injections. Fasel based this computation on Andersen's report of three fatalities which occurred within a 4-year period in Denmark (5). Welch and associates (17), in a report of a nationwide !survey undertaken with the cooperation of 800 hospitals and 1,500 physicians, stated: In 1956 about 2,500,000 pounds of antibiotics were produced in the United States of America-penicillin accounts for 960,000 pounds (38 percent). Of a total of 2,995 cases reported as severe reactions, 2,517 were associated with the use of penicillin. Thus, penicillin was involved in 80 percent of all reactions reviewed in this survey. The authors concluded: is obvious that penicillin is the antibiotic causing the greatest number of reactions and the one most frequently involved in fatal cases. It is clear also that the oral route is the much safer method of administration, both from the standpoint of numbers of reactions and of mortality. The vast majority of Dr. Popper, dermatologist and clinical syphilologist, directed the venereal disease clinic of the central district of the Los Angeles (Calif.) Health Department.