“We recently encountered a case of accidental intravenous injection of chlorhexidine gluconate in a patient posted for coronary artery bypass surgery when after uneventful induction of anesthesia, the surgeon started preparing the right groin for IABP insertion, simultaneously with central line insertion by the anesthetist and accidentally kept the gallipot containing almost colorless chlorhexidine solution for surgical site preparation on the sterile tray meant for central venous catheter insertion (Fig. 1A). The anesthetist, mistaking the same as heparin–saline solution, inadvertently injected undiluted 2 mL (40 mg) of chlorhexidine gluconate solution intravenously while flushing a central venous catheter port, without any adverse consequences to the patient.”Reference:
Dogra N, Goswami D, Kumar S. A not so rosy picture: accidental intravenous injection of rose-tinted pourable chlorhexidine solution. Braz J Anesthesiol. 2021 Oct 8:S0104-0014(21)00377-8. doi: 10.1016/j.bjane.2021.09.018. Epub ahead of print. PMID: 34634316.