A term male infant with pneumonia was receiving fluid and antibiotics through an intravenous line in the scalp. Air was accidentally infused in this line. Subsequently, discoloration of the skin, a flaccid paraplegia, hematuria, and gastrointestinal bleeding occurred as the presumed effect of venous air entering the systemic arteries. The umbilical vessels were never catheterized. Absence of any apparent cerebral air embolism is interpreted as being due to the infant's position (head down) at the time of air infusion. The pathogeneis and prevention of this tragic complication are discussed.
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