Phenytoin intoxication due to an error in the administration of fosphenytoin.

Following surgery for a chronic subdural haematoma, a 74-year-old patient r eceived fosphenytoin as prophylaxis for epilepsy. The patient received 10 t imes the prescribed dose. This error in the administration of fosphenytoine was facilitated by a conf using labeling of the product. The phenytoin blo od level was 79 mug.ml(-1). The main adverse effect was a coma requiring 5 days of mechanical ventilation. No adverse cardiovascular event was noted. The phenytoin blood levels returned toward the therapeutic range in 8 days. At discharge from the hospital 20 days after surgery, the patient did not have any sequela from the fosphenytoin intoxication. (C) 2000 Editions scie ntifiques et medicales Elsevier SAS.