[Accidental central venous administation of 0.1 % chlorhexidine mouthwash]. / Akzidentelle zentralvenöse Verabreichung von 0,1 %iger Chlorhexidinmundspüllösung.

Medication errors are frequent and a serious safety concern. Chlorhexidine (CHX) is used daily in healthcare as a disinfectant. Its accidental intravascular injection is scarcely described. Serious complications, such as acute respiratory distress syndrome (ARDS) could be a consequence. We describe a case of central venous administration of 0.1% CHX mouthwash, its potential complications and possibilities of treatment. In contrast to another case report our patient had no detectable adverse side effects. The immediate hemofiltration and cleansing of the i. v. line may have contributed to this favorable outcome.