A massive intrathecal cefazoline overdose

This case report describes the clinical course of a patient who inadvertent ly received a massive intrathecal cefazoline overdose through a lumbar drai n, which had been placed after trans-sphenoidal surgery for a pituitary ade noma. She received high-dose barbiturate therapy and was monitored with ele ctroencephalography (EEG), somatosensory evoked potentials (SSEP), brainste m auditory evoked potentials (BAEP) and transcranial Doppler ultrasound (TC D). No cerebrospinal fluid (CSF) exchange was performed, but CSF was draine d continuously with daily CSF-cefazoline level monitoring. Despite the extr emely toxic dose, the patient soon recovered completely.