Resumen de Adverse event due to flow meter failure related to nebulization of caspofungin

José Marco Del Río, Pablo Cuesta Montero, Jose-Vicente Catalá Ripoll, Esther Domingo Chiva, Eva María García Martínez, Francisca Sánchez Rubio, Marca Díaz Rangel

• Nebulized route is increasingly used to administer drugs among critical care units despite of bibliographic data being limited. Therefore, many times it is performed in an empiric way that could increase the probability of complications. We present the case of a patient that, being under pressure controlled ventilation, was treated with nebulized caspofungin. After that, he presented a respiratory rate higher than 40 respirations per minute, desaturation, bradycardia and hypotension. After removing and reviewing the ventilator, a deposit of crystallized drug was observed on the flow meter. Nebulization of drugs is performed wrongly too many times and has some important complications, so it seems a priority to elaborate guides in order to increase patient's safety